FUNDAMENTALS OF NURSING 1. A facility has a system for transcribing medication orders to a Kardex as well as a computerizedmedication administration record (MAR).

A physician writes the following order for a client: "Prednisone 5 mg P.O. daily for 3 days." The order is correctly transcribed on the Kardex. However, the nurse who transcribes the order onto the MAR neglects to place the limitation of 3 days on the prescription. On the 4th day after the order was instituted, a nurse administers prednisone 5 mg P.O. During an audit of the chart, the error is identified. The person most responsible for the error is the: a. nurse who transcribed the order incorrectly on the MAR b. nurse who administered the erroneous dose. c. pharmacist who filled the order and provided the erroneous dose. d. facility because of its policy on transcription of medications. 2. To evaluate a client's chief complaint, the nurse performs deep palpation. The purpose of deep palpation is to assess which of the following? a. Skin turgor b. Hydration c. Organs d. Temperature 3. One of the nursing fundamentals questions is about giving an I.M. injection, the nurse should insert the needle into the muscle at an angle of: a. 15 degrees. b. 30 degrees. c. 45 degrees. d. 90 degrees. 4. A client, age 43, has no family history of breast cancer or other risk factors for this disease. The nurse should instruct her to have a mammogram how often

client vomits and begins choking. Which of the following actions is most appropriate for the nurse to take? a. Clear the client's airway. b. Make the client comfortable. c. Start cardiopulmonary resuscitation. d. Stop the feeding and remove the NG tube. 8. The nurse is caring for a geriatric client with a pressure ulcer on the sacrum. When teaching the client about fundamentals in nursing on dietary intake, which foods should the nurse plan to emphasize? a. Legumes and cheese b. Whole grain products c. Fruits and vegetables d. Lean meats and low-fat milk 9. A client with chronic renal failure is admitted with a heart rate of 122 beats/minute, a respiratory rate of 32 breaths/minute, a blood pressure of 190/110 mm Hg, neck vein distention, and bibasilar crackles. Which nursing diagnosis takes highest priority for this client? a. Fear b. Urinary retention c. Excessive fluid volume d. Self-care deficient: Toileting 10. A client's blood test results are as follows: white blood cell (WBC) count is 1,000/l; hemoglobin (Hb) level, 14 g/dl; hematocrit (HCT), 42%. Which of the following goals would be most important for this client? a. Promote fluid balance b. Prevent infection. c. Promote rest. d. Prevent injury.

Answers and Rationale a. Once, to establish a baseline b. Once per year c. Every 2 years d. Twice per year 5. When prioritizing a client's plan of care based on Maslow's hierarchy of needs, the nurse's first priority would be: a. allowing the family to see a newly admitted client. b. ambulating the client in the hallway. c. administering pain medication d. placing wrist restraints on the client. 6. A 49-year-old client with acute respiratory distress watches everything the staff does and demands full explanations for all procedures and medications. Which of the following actions would best indicate that the client has achieved an increased level of psychological comfort? a. Making decreased eye contact b. Asking to see family members c. Joking about the present condition d. Sleeping undisturbed for 3 hours 7. A hospitalized client who has a living will is being fed through a nasogastric (NG) tube. During a bolus feeding, the 1) B - The nurse administering the dose should have compared the MAR with the Kardex and noted the discrepancy. The transcribing nurse and pharmacist aren't void of responsibility; however, the nurse administering the dose is most responsible. The facility's policy does provide for a system of checks and balances. Therefore, the facility isn't responsible for the error. 2) C - The purpose of deep palpation, in which the nurse indents the client's skin approximately 1" (3.8 cm), is to assess underlying organs and structures, such as the kidneys and spleen. Skin turgor, hydration, and temperature can be assessed by using light touch or light palpation 3) D Nursing Fundamentals Questions Rationale: When giving an I.M. injection, the nurse inserts the needle into the muscle at a 90-degree angle, using a quick, dartlike motion. A 15-degree angle is appropriate when administering an intradermal injection. A 30-degree angle isn't used for any type of injection. A 45- or 90-degree angle can be used when giving a subcutaneous injection

4) C - A client age 40 to 49 with no family history of breast cancer or other risk factors for this disease should have a mammogram every 2 years. After age 50, the client should have a mammogram every year 5) C - In Maslow's hierarchy of needs, pain relief is on the first layer. Activity (option B) is on the second layer. Safety (option D) is on the third layer. Love and belonging (option A) are on the fourth layer. 6) D - Sleeping undisturbed for a period of time would indicate that the client feels more relaxed, comfortable, and trusting and is less anxious. Decreasing eye contact, asking to see family, and joking may also indicate that the client is more relaxed. However, these also could be diversions. 7) A - A living will states that no life-saving measures are to be used in terminal conditions. There is no indication that the client is terminally ill. Furthermore, a living will doesn't apply to nonterminal events such as choking on an enteral feeding device. The nurse should clear the client's airway. Making the client comfortable ignores the life-threatening event. Cardiopulmonary resuscitation isn't indicated, and removing the NG tube would exacerbate the situation 8) D - Although the client should eat a balanced diet with foods from all food groups, the diet should emphasize foods that supply complete protein, such as lean meats and low-fat milk, because protein helps build and repair body tissue, which promotes healing. Fundamentals in nursing teaches that legumes provide incomplete protein. Cheese contains complete protein, but also fat, which should be limited to 30% or less of caloric intake. Whole grain products supply incomplete proteins and carbohydrates. Fruits and vegetables provide mainly carbohydrates. 9) C - A client with renal failure can't eliminate sufficient fluid, increasing the risk of fluid overload and consequent respiratory and electrolyte problems. This client has signs of excessive fluid volume and is acutely ill. Fear and a toileting self-care deficit may be problems, but they take lower priority because they aren't life-threatening. Urinary retention may cause renal failure but is a less urgent concern than fluid imbalance. 10) B - The client is at risk for infection because the WBC count is dangerously low. Hb level and HCT are within normal limits; therefore, fluid balance, rest, and prevention of injury are inappropriate.

tachypneic. The nurse understands that tachypnea means: a. Pulse rate greater than 100 beats per minute b. Blood pressure of 140/90 c. Respiratory rate greater than 20 breaths per minute d. Frequent bowel sounds 2. The nurse listens to Mrs. Sullens lungs and notes a hissing sound or musical sound. The nurse documents this as: a. Wheezes b. Rhonchi c. Gurgles d. Vesicular 3. The nurse in charge measures a patients temperature at 101 degrees F. What is the equivalent centigrade temperature? a. 36.3 degrees C b. 37.95 degrees C c. 40.03 degrees C d. 38.01 degrees C 4. Which approach to problem solving tests any number of solutions until one is found that works for that particular problem? a. Intuition b. Routine c. Scientific method d. Trial and error 5. What is the order of the nursing process? a. Assessing, diagnosing, implementing, evaluating, planning b. Diagnosing, assessing, planning, implementing, evaluating c. Assessing, diagnosing, planning, implementing, evaluating d. Planning, evaluating, diagnosing, assessing, implementing 6. During the planning phase of the nursing process, which of the following is the outcome? a. Nursing history b. Nursing notes c. Nursing care plan d. Nursing diagnosis 7. What is an example of a subjective data? a. Heart rate of 68 beats per minute b. Yellowish sputum c. Client verbalized, I feel pain when urinating. d. Noisy breathing 8. Which expected outcome is correctly written?

Nursing Board Review: Fundamentals of Nursing Practice Test Part 1 http://www.rnpedia.com/home/exams/philippine-boardexam-nle/nursing-board-review-fundamentals-of-nursingpractice-test-part-1 1. Jake is complaining of shortness of breath. The nurse assesses his respiratory rate to be 30 breaths per minute and documents that Jake is

a. The patient will feel less nauseated in 24 hours. b. The patient will eat the right amount of food daily. c. The patient will identify all the high-salt food from a prepared list by discharge. d. The patient will have enough sleep. 9. Which of the following behaviors by Nurse Jane Robles demonstrates that she understands well th elements of effecting charting? a. She writes in the chart using a no. 2 pencil. b. She noted: appetite is good this afternoon. c. She signs on the medication sheet after administering the medication. d. She signs her charting as follow: J.R 10. What is the disadvantage of computerized documentation of the nursing process? a. Accuracy b. Legibility c. Concern for privacy d. Rapid communication 11. The theorist who believes that adaptation and manipulation of stressors are related to foster change is: a. Dorothea Orem b. Sister Callista Roy c. Imogene King d. Virginia Henderson 12. Formulating a nursing diagnosis is a joint function of: a. Patient and relatives b. Nurse and patient c. Doctor and family d. Nurse and doctor 13. Mrs. Caperlac has been diagnosed to have hypertension since 10 years ago. Since then, she had maintained low sodium, low fat diet, to control her blood pressure. This practice is viewed as: a. Cultural belief b. Personal belief c. Health belief d. Superstitious belief 14. Becky is on NPO since midnight as preparation for blood test. Adreno-cortical response is activated. Which of the following is an expected response? a. Low blood pressure b. Warm, dry skin c. Decreased serum sodium levels d. Decreased urine output

15. What nursing action is appropriate when obtaining a sterile urine specimen from an indwelling catheter to prevent infection? a. Use sterile gloves when obtaining urine. b. Open the drainage bag and pour out the urine. c. Disconnect the catheter from the tubing and get urine. d. Aspirate urine from the tubing port using a sterile syringe. 16. A client is receiving 115 ml/hr of continuous IVF. The nurse notices that the venipuncture site is red and swollen. Which of the following interventions would the nurse perform first? a. Stop the infusion b. Call the attending physician c. Slow that infusion to 20 ml/hr d. Place a clod towel on the site 17. The nurse enters the room to give a prescribed medication but the patient is inside the bathroom. What should the nurse do? a. Leave the medication at the bedside and leave the room. b. After few minutes, return to that patients room and do not leave until the patient takes the medication. c. Instruct the patient to take the medication and leave it at the bedside. d. Wait for the patient to return to bed and just leave the medication at the bedside. 18. Which of the following is inappropriate nursing action when administering NGT feeding? a. Place the feeding 20 inches above the pint if insertion of NGT. b. Introduce the feeding slowly. c. Instill 60ml of water into the NGT after feeding. d. Assist the patient in fowlers position. 19. A female patient is being discharged after thyroidectomy. After providing the medication teaching. The nurse asks the patient to repeat the instructions. The nurse is performing which professional role? a. Manager b. Caregiver c. Patient advocate d. Educator 20. Which data would be of greatest concern to the nurse when completing the nursing assessment of a 68-year-old woman hospitalized due to Pneumonia? a. Oriented to date, time and place b. Clear breath sounds c. Capillary refill greater than 3 seconds and buccal cyanosis d. Hemoglobin of 13 g/dl

21. During a change-of-shift report, it would be important for the nurse relinquishing responsibility for care of the patient to communicate. Which of the following facts to the nurse assuming responsibility for care of the patient? a. That the patient verbalized, My headache is gone. b. That the patients barium enema performed 3 days ago was negative c. Patients NGT was removed 2 hours ago d. Patients family came for a visit this morning. 22. Which statement is the most appropriate goal for a nursing diagnosis of diarrhea? a. The patient will experience decreased frequency of bowel elimination. b. The patient will take anti-diarrheal medication. c. The patient will give a stool specimen for laboratory examinations. d. The patient will save urine for inspection by the nurse. 23. Which of the following is the most important purpose of planning care with this patient? a. Development of a standardized NCP. b. Expansion of the current taxonomy of nursing diagnosis c. Making of individualized patient care d. Incorporation of both nursing and medical diagnoses in patient care 24. Using Maslows hierarchy of basic human needs, which of the following nursing diagnoses has the highest priority? a. Ineffective breathing pattern related to pain, as evidenced by shortness of breath. b. Anxiety related to impending surgery, as evidenced by insomnia. c. Risk of injury related to autoimmune dysfunction d. Impaired verbal communication related to tracheostomy, as evidenced by inability to speak. 25. When performing an abdominal examination, the patient should be in a supine position with the head of the bed at what position? a. 30 degrees b. 90 degrees c. 45 degrees d. 0 degree Answer and Rationale : Fundamentals in Nursing Practice Test Part 1 1. (C) Respiratory rate greater than 20 breaths per minute

A respiratory rate of greater than 20 breaths per minute is tachypnea. A blood pressure of 140/90 is considered hypertension. Pulse greater than 100 beats per minute is tachycardia. Frequent bowel sounds refer to hyper-active bowel sounds. 2. (A) Wheezes Wheezes are indicated by continuous, lengthy, musical; heard during inspiration or expiration. Rhonchi are usually coarse breath sounds. Gurgles are loud gurgling, bubbling sound. Vesicular breath sounds are low pitch, soft intensity on expiration. 3. (B) 37.95 degrees C To convert F to C use this formula, ( F 32 ) (0.55). While when converting C to F use this formula, ( C x 1.8) + 32. Note that 0.55 is 5/9 and 1.8 is 9/5. 4. (D) Trial and error The trial and error method of problem solving isnt systematic (as in the scientific method of problem solving) routine, or based on inner prompting (as in the intuitive method of problem solving). 5. (C) Assessing, diagnosing, planning, implementing, evaluating The correct order of the nursing process is assessing, diagnosing, planning, implementing, evaluating. 6. (C) Nursing care plan The outcome, or the product of the planning phase of the nursing process is a Nursing care plan. 7. (C) Client verbalized, I feel pain when urinating. Subjective data are those that can be described only by the person experiencing it. Therefore, only the patient can describe or verify whether he is experiencing pain or not. 8. (C) The patient will identify all the highsalt food from a prepared list by discharge. Expected outcomes are specific, measurable, realistic statements of goal attainment. The phrases right amount, less nauseated and enough sleep are vague and not measurable. 9. (C) She signs on the medication sheet after administering the medication. A nurse should record a nursing intervention (ex. Giving medications) after performing the nursing intervention (not before). Recording should also be done using a pen, be complete, and signed with the nurses full name and title. 10. (C) Concern for privacy A patients privacy may be violated if security measures arent used properly or if policies and procedures arent in place that determines what type of information can be retrieved, by whom, and for what purpose. 11. (B) Sister Callista Roy Sister Roys theory is called the adaptation theory and she viewed each person as a unified

biophysical system in constant interaction with a changing environment. Orems theory is called self-care deficit theory and is based on the belief that individual has a need for self-care actions. Kings theory is the Goal attainment theory and described nursing as a helping profession that assists individuals and groups in society to attain, maintain, and restore health. Henderson introduced the nature of nursing model and identified the 14 basic needs. 12. (B) Nurse and patient Although diagnosing is basically the nurses responsibility, input from the patient is essential to formulate the correct nursing diagnosis. 13. (C) Health belief Health belief of an individual influences his/her preventive health behavior. 14. (D) Decreased urine output Adreno-cortical response involves release of aldosterone that leads to retention of sodium and water. This results to decreased urine output. 15. (D) Aspirate urine from the tubing port using a sterile syringe. The nurse should aspirate the urine from the port using a sterile syringe to obtain a urine specimen. Opening a closed drainage system increase the risk of urinary tract infection. 16. (A) Stop the infusion The sign and symptoms indicate extravasation so the IVF should be stopped immediately and put warm not cold towel on the affected site. 17. (B) After few minutes, return to that patients room and do not leave until the patient takes the medication This is to verify or to make sure that the medication was taken by the patient as directed. 18. (A) Place the feeding 20 inches above the pint if insertion of NGT. The height of the feeding is above 12 inches above the point of insertion, bot 20 inches. If the height of feeding is too high, this results to very rapid introduction of feeding. This may trigger nausea and vomiting. 19. (D) Educator When teaching a patient about medications before discharge, the nurse is acting as an educator. A caregiver provides direct care to the patient. The nurse acts as s patient advocate when making the patients wishes known to the doctor. 20. (C) Capillary refill greater than 3 seconds and buccal cyanosis Capillary refill greater than 3 seconds and buccal cyanosis indicate decreased oxygen to the tissues which requires immediate attention/intervention. Oriented to date, time and place, hemoglobin of 13 g/dl are normal data. 21. (C) Patients NGT was removed 2 hours ago The change-of-shift report should indicate significant recent changes in the patients

condition that the nurse assuming responsibility for care of the patient will need to monitor. The other options are not critical enough to include in the report. 22. (A) The patient will experience decreased frequency of bowel elimination. The goal is the opposite, healthy response of the problem statement of the nursing diagnosis. In this situation, the problem statement is diarrhea. 23. (C) Making of individualized patient care To be effective, the nursing care plan developed in the planning phase of the nursing process must reflect the individualized needs of the patient. 24. (A) Ineffective breathing pattern related to pain, as evidenced by shortness of breath. Physiologic needs (ex. Oxygen, fluids, nutrition) must be met before lower needs (such as safety and security, love and belongingness, selfesteem and self-actualization) can be met. Therefore, physiologic needs have the highest priority. 25. (D) 0 degree The patient should be positioned with the head of the bed completely flattened to perform an abdominal examination. If the head of the bed is elevated, the abdominal muscles and organs can be bunched up, altering the findings

Practice Test I -Foundation of Nursing http://www.rnpedia.com/home/exams/philippine-boardexam-nle/practice-test-i--foundation-of-nursing-1 1. Which element in the circular chain of infection can be eliminated by preserving skin integrity? a. Host b. Reservoir c. Mode of transmission d. Portal of entry 2. Which of the following will probably result in a break in sterile technique for respiratory isolation? a. Opening the patients window to the outside environment b. Turning on the patients room ventilator c. Opening the door of the patients room leading into the hospital corridor d. Failing to wear gloves when administering a bed bath 3. Which of the following patients is at greater risk for contracting an infection? a. A patient with leukopenia b. A patient receiving broad-spectrum antibiotics c. A postoperative patient who has undergone orthopedic surgery

d. A newly diagnosed diabetic patient 4. Effective hand washing requires the use of: a. Soap or detergent to promote emulsification b. Hot water to destroy bacteria c. A disinfectant to increase surface tension d. All of the above 5. After routine patient contact, hand washing should last at least: a. 30 seconds b. 1 minute c. 2 minute d. 3 minutes 6. Which of the following procedures always requires surgical asepsis? a. Vaginal instillation of conjugated estrogen b. Urinary catheterization c. Nasogastric tube insertion d. Colostomy irrigation 7. Sterile technique is used whenever: a. Strict isolation is required b. Terminal disinfection is performed c. Invasive procedures are performed d. Protective isolation is necessary 8. Which of the following constitutes a break in sterile technique while preparing a sterile field for a dressing change? a. Using sterile forceps, rather than sterile gloves, to handle a sterile item b. Touching the outside wrapper of sterilized material without sterile gloves c. Placing a sterile object on the edge of the sterile field d. Pouring out a small amount of solution (15 to 30 ml) before pouring the solution into a sterile container 9. A natural body defense that plays an active role in preventing infection is: a. Yawning b. Body hair c. Hiccupping d. Rapid eye movements 10. All of the following statement are true about donning sterile gloves except: a. The first glove should be picked up by grasping the inside of the cuff. b. The second glove should be picked up by inserting the gloved fingers under the cuff outside the glove.

c. The gloves should be adjusted by sliding the gloved fingers under the sterile cuff and pulling the glove over the wrist d. The inside of the glove is considered sterile 11.When removing a contaminated gown, the nurse should be careful that the first thing she touches is the: a. Waist tie and neck tie at the back of the gown b. Waist tie in front of the gown c. Cuffs of the gown d. Inside of the gown 12.Which of the following nursing interventions is considered the most effective form or universal precautions? a. Cap all used needles before removing them from their syringes b. Discard all used uncapped needles and syringes in an impenetrable protective container c. Wear gloves when administering IM injections d. Follow enteric precautions 13.All of the following measures are recommended to prevent pressure ulcers except: a. Massaging the reddened are with lotion b. Using a water or air mattress c. Adhering to a schedule for positioning and turning d. Providing meticulous skin care 14.Which of the following blood tests should be performed before a blood transfusion? a. Prothrombin and coagulation time b. Blood typing and cross-matching c. Bleeding and clotting time d. Complete blood count (CBC) and electrolyte levels. 15.The primary purpose of a platelet count is to evaluate the: a. Potential for clot formation b. Potential for bleeding c. Presence of an antigen-antibody response d. Presence of cardiac enzymes 16.Which of the following white blood cell (WBC) counts clearly indicates leukocytosis? a. 4,500/mm b. 7,000/mm c. 10,000/mm d. 25,000/mm 17. After 5 days of diuretic therapy with 20mg of furosemide (Lasix) daily, a patient begins to exhibit fatigue, muscle cramping and muscle weakness. These symptoms probably indicate that the patient is experiencing:

a. Hypokalemia b. Hyperkalemia c. Anorexia d. Dysphagia 18.Which of the following statements about chest X-ray is false? a. No contradictions exist for this test b. Before the procedure, the patient should remove all jewelry, metallic objects, and buttons above the waist c. A signed consent is not required d. Eating, drinking, and medications are allowed before this test 19.The most appropriate time for the nurse to obtain a sputum specimen for culture is: a. Early in the morning b. After the patient eats a light breakfast c. After aerosol therapy d. After chest physiotherapy 20.A patient with no known allergies is to receive penicillin every 6 hours. When administering the medication, the nurse observes a fine rash on the patients skin. The most appropriate nursing action would be to: a. Withhold the moderation and notify the physician b. Administer the medication and notify the physician c. Administer the medication with an antihistamine d. Apply corn starch soaks to the rash 21.All of the following nursing interventions are correct when using the Ztrack method of drug injection except: a. Prepare the injection site with alcohol b. Use a needle thats a least 1 long c. Aspirate for blood before injection d. Rub the site vigorously after the injection to promote absorption 22.The correct method for determining the vastus lateralis site for I.M. injection is to: a. Locate the upper aspect of the upper outer quadrant of the buttock about 5 to 8 cm below the iliac crest b. Palpate the lower edge of the acromion process and the midpoint lateral aspect of the arm c. Palpate a 1 circular area anterior to the umbilicus d. Divide the area between the greater femoral trochanter and the lateral femoral condyle into thirds, and select the middle third on the anterior of the thigh

23.The mid-deltoid injection site is seldom used for I.M. injections because it: a. Can accommodate only 1 ml or less of medication b. Bruises too easily c. Can be used only when the patient is lying down d. Does not readily parenteral medication 24.The appropriate needle size for insulin injection is: a. 18G, 1 long b. 22G, 1 long c. 22G, 1 long d. 25G, 5/8 long 25.The appropriate needle gauge for intradermal injection is: a. 20G b. 22G c. 25G d. 26G 26.Parenteral penicillin can be administered as an: a. IM injection or an IV solution b. IV or an intradermal injection c. Intradermal or subcutaneous injection d. IM or a subcutaneous injection 27.The physician orders gr 10 of aspirin for a patient. The equivalent dose in milligrams is: a. 0.6 mg b. 10 mg c. 60 mg d. 600 mg 28.The physician orders an IV solution of dextrose 5% in water at 100ml/hour. What would the flow rate be if the drop factor is 15 gtt = 1 ml? a. 5 gtt/minute b. 13 gtt/minute c. 25 gtt/minute d. 50 gtt/minute 29.Which of the following is a sign or symptom of a hemolytic reaction to blood transfusion? a. Hemoglobinuria b. Chest pain c. Urticaria d. Distended neck veins 30.Which of the following conditions may require fluid restriction? a. Fever

b. Chronic Obstructive Pulmonary Disease c. Renal Failure d. Dehydration 31.All of the following are common signs and symptoms of phlebitis except: a. Pain or discomfort at the IV insertion site b. Edema and warmth at the IV insertion site c. A red streak exiting the IV insertion site d. Frank bleeding at the insertion site 32.The best way of determining whether a patient has learned to instill ear medication properly is for the nurse to: a. Ask the patient if he/she has used ear drops before b. Have the patient repeat the nurses instructions using her own words c. Demonstrate the procedure to the patient and encourage to ask questions d. Ask the patient to demonstrate the procedure 33.Which of the following types of medications can be administered via gastrostomy tube? a. Any oral medications b. Capsules whole contents are dissolve in water c. Enteric-coated tablets that are thoroughly dissolved in water d. Most tablets designed for oral use, except for extended-duration compounds 34.A patient who develops hives after receiving an antibiotic is exhibiting drug: a. Tolerance b. Idiosyncrasy c. Synergism d. Allergy 35.A patient has returned to his room after femoral arteriography. All of the following are appropriate nursing interventions except: a. Assess femoral, popliteal, and pedal pulses every 15 minutes for 2 hours b. Check the pressure dressing for sanguineous drainage c. Assess a vital signs every 15 minutes for 2 hours d. Order a hemoglobin and hematocrit count 1 hour after the arteriography 36.The nurse explains to a patient that a cough: a. Is a protective response to clear the respiratory tract of irritants b. Is primarily a voluntary action c. Is induced by the administration of an antitussive drug d. Can be inhibited by splinting the abdomen

37.An infected patient has chills and begins shivering. The best nursing intervention is to: a. Apply iced alcohol sponges b. Provide increased cool liquids c. Provide additional bedclothes d. Provide increased ventilation 38.A clinical nurse specialist is a nurse who has: a. Been certified by the National League for Nursing b. Received credentials from the Philippine Nurses Association c. Graduated from an associate degree program and is a registered professional nurse d. Completed a masters degree in the prescribed clinical area and is a registered professional nurse. 39.The purpose of increasing urine acidity through dietary means is to: a. Decrease burning sensations b. Change the urines color c. Change the urines concentration d. Inhibit the growth of microorganisms 40.Clay colored stools indicate: a. Upper GI bleeding b. Impending constipation c. An effect of medication d. Bile obstruction 41.In which step of the nursing process would the nurse ask a patient if the medication she administered relieved his pain? a. Assessment b. Analysis c. Planning d. Evaluation 42.All of the following are good sources of vitamin A except: a. White potatoes b. Carrots c. Apricots d. Egg yolks 43.Which of the following is a primary nursing intervention necessary for all patients with a Foley Catheter in place? a. Maintain the drainage tubing and collection bag level with the patients bladder b. Irrigate the patient with 1% Neosporin solution three times a daily c. Clamp the catheter for 1 hour every 4 hours to maintain the bladders elasticity d. Maintain the drainage tubing and collection bag below bladder level to facilitate drainage by gravity

44.The ELISA test is used to: a. Screen blood donors for antibodies to human immunodeficiency virus (HIV) b. Test blood to be used for transfusion for HIV antibodies c. Aid in diagnosing a patient with AIDS d. All of the above 45.The two blood vessels most commonly used for TPN infusion are the: a. Subclavian and jugular veins b. Brachial and subclavian veins c. Femoral and subclavian veins d. Brachial and femoral veins 46.Effective skin disinfection before a surgical procedure includes which of the following methods? a. Shaving the site on the day before surgery b. Applying a topical antiseptic to the skin on the evening before surgery c. Having the patient take a tub bath on the morning of surgery d. Having the patient shower with an antiseptic soap on the evening v=before and the morning of surgery 47.When transferring a patient from a bed to a chair, the nurse should use which muscles to avoid back injury? a. Abdominal muscles b. Back muscles c. Leg muscles d. Upper arm muscles 48.Thrombophlebitis typically develops in patients with which of the following conditions? a. Increases partial thromboplastin time b. Acute pulsus paradoxus c. An impaired or traumatized blood vessel wall d. Chronic Obstructive Pulmonary Disease (COPD) 49.In a recumbent, immobilized patient, lung ventilation can become altered, leading to such respiratory complications as: a. Respiratory acidosis, ateclectasis, and hypostatic pneumonia b. Appneustic breathing, atypical pneumonia and respiratory alkalosis c. Cheyne-Strokes respirations and spontaneous pneumothorax d. Kussmails respirations and hypoventilation 50.Immobility impairs bladder elimination, resulting in such disorders as

a. Increased urine acidity and relaxation of the perineal muscles, causing incontinence b. Urine retention, bladder distention, and infection c. Diuresis, natriuresis, and decreased urine specific gravity d. Decreased calcium and phosphate levels in the urine Answer and Rationale- Practice Test I Foundation of Nursing 1. D. In the circular chain of infection, pathogens must be able to leave their reservoir and be transmitted to a susceptible host through a portal of entry, such as broken skin. 2. C. Respiratory isolation, like strict isolation, requires that the door to the door patients room remain closed. However, the patients room should be well ventilated, so opening the window or turning on the ventricular is desirable. The nurse does not need to wear gloves for respiratory isolation, but good hand washing is important for all types of isolation. 3. A. Leukopenia is a decreased number of leukocytes (white blood cells), which are important in resisting infection. None of the other situations would put the patient at risk for contracting an infection; taking broadspectrum antibiotics might actually reduce the infection risk. 4. A. Soaps and detergents are used to help remove bacteria because of their ability to lower the surface tension of water and act as emulsifying agents. Hot water may lead to skin irritation or burns. 5. A. Depending on the degree of exposure to pathogens, hand washing may last from 10 seconds to 4 minutes. After routine patient contact, hand washing for 30 seconds effectively minimizes the risk of pathogen transmission. 6. B. The urinary system is normally free of microorganisms except at the urinary meatus. Any procedure that involves entering this system must use surgically aseptic measures to maintain a bacteria-free state. 7. C. All invasive procedures, including surgery, catheter insertion, and administration of parenteral therapy, require sterile technique to maintain a sterile environment. All equipment must be sterile, and the nurse and the physician must wear sterile gloves and maintain surgical asepsis. In the operating room, the nurse and physician are required to wear sterile gowns, gloves, masks, hair covers, and shoe covers for all invasive procedures. Strict isolation requires the use of clean gloves, masks, gowns and equipment to prevent the transmission of highly communicable diseases by contact or by airborne routes. Terminal disinfection is the disinfection of all contaminated supplies and equipment after a patient has been discharged to prepare them for reuse by another patient. The purpose of

protective (reverse) isolation is to prevent a person with seriously impaired resistance from coming into contact who potentially pathogenic organisms. 8. C. The edges of a sterile field are considered contaminated. When sterile items are allowed to come in contact with the edges of the field, the sterile items also become contaminated. 9. B. Hair on or within body areas, such as the nose, traps and holds particles that contain microorganisms. Yawning and hiccupping do not prevent microorganisms from entering or leaving the body. Rapid eye movement marks the stage of sleep during which dreaming occurs. 10. D. The inside of the glove is always considered to be clean, but not sterile. 11. A. The back of the gown is considered clean, the front is contaminated. So, after removing gloves and washing hands, the nurse should untie the back of the gown; slowly move backward away from the gown, holding the inside of the gown and keeping the edges off the floor; turn and fold the gown inside out; discard it in a contaminated linen container; then wash her hands again. 12. B. According to the Centers for Disease Control (CDC), blood-to-blood contact occurs most commonly when a health care worker attempts to cap a used needle. Therefore, used needles should never be recapped; instead they should be inserted in a specially designed puncture resistant, labeled container. Wearing gloves is not always necessary when administering an I.M. injection. Enteric precautions prevent the transfer of pathogens via feces. 13. A. Nurses and other health care professionals previously believed that massaging a reddened area with lotion would promote venous return and reduce edema to the area. However, research has shown that massage only increases the likelihood of cellular ischemia and necrosis to the area. 14. B. Before a blood transfusion is performed, the blood of the donor and recipient must be checked for compatibility. This is done by blood typing (a test that determines a persons blood type) and cross-matching (a procedure that determines the compatibility of the donors and recipients blood after the blood types has been matched). If the blood specimens are incompatible, hemolysis and antigen-antibody reactions will occur. 15. A. Platelets are disk-shaped cells that are essential for blood coagulation. A platelet count determines the number of thrombocytes in blood available for promoting hemostasis and assisting with blood coagulation after injury. It also is used to evaluate the patients potential for bleeding; however, this is not its primary purpose. The normal count ranges from 150,000 to 350,000/mm3. A count of 100,000/mm3 or less indicates a potential for bleeding; count of

less than 20,000/mm3 is associated with spontaneous bleeding. 16. D. Leukocytosis is any transient increase in the number of white blood cells (leukocytes) in the blood. Normal WBC counts range from 5,000 to 100,000/mm3. Thus, a count of 25,000/mm3 indicates leukocytosis. 17. A. Fatigue, muscle cramping, and muscle weaknesses are symptoms of hypokalemia (an inadequate potassium level), which is a potential side effect of diuretic therapy. The physician usually orders supplemental potassium to prevent hypokalemia in patients receiving diuretics. Anorexia is another symptom of hypokalemia. Dysphagia means difficulty swallowing. 18. A. Pregnancy or suspected pregnancy is the only contraindication for a chest X-ray. However, if a chest X-ray is necessary, the patient can wear a lead apron to protect the pelvic region from radiation. Jewelry, metallic objects, and buttons would interfere with the X-ray and thus should not be worn above the waist. A signed consent is not required because a chest X-ray is not an invasive examination. Eating, drinking and medications are allowed because the X-ray is of the chest, not the abdominal region. 19. A. Obtaining a sputum specimen early in this morning ensures an adequate supply of bacteria for culturing and decreases the risk of contamination from food or medication. 20. A. Initial sensitivity to penicillin is commonly manifested by a skin rash, even in individuals who have not been allergic to it previously. Because of the danger of anaphylactic shock, he nurse should withhold the drug and notify the physician, who may choose to substitute another drug. Administering an antihistamine is a dependent nursing intervention that requires a written physicians order. Although applying corn starch to the rash may relieve discomfort, it is not the nurses top priority in such a potentially life-threatening situation. 21. D. The Z-track method is an I.M. injection technique in which the patients skin is pulled in such a way that the needle track is sealed off after the injection. This procedure seals medication deep into the muscle, thereby minimizing skin staining and irritation. Rubbing the injection site is contraindicated because it may cause the medication to extravasate into the skin. 22. D. The vastus lateralis, a long, thick muscle that extends the full length of the thigh, is viewed by many clinicians as the site of choice for I.M. injections because it has relatively few major nerves and blood vessels. The middle third of the muscle is recommended as the injection site. The patient can be in a supine or sitting position for an injection into this site. 23. A. The mid-deltoid injection site can accommodate only 1 ml or less of medication

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because of its size and location (on the deltoid muscle of the arm, close to the brachial artery and radial nerve). 24. D. A 25G, 5/8 needle is the recommended size for insulin injection because insulin is administered by the subcutaneous route. An 18G, 1 needle is usually used for I.M. injections in children, typically in the vastus lateralis. A 22G, 1 needle is usually used for adult I.M. injections, which are typically administered in the vastus lateralis or ventrogluteal site. 25. D. Because an intradermal injection does not penetrate deeply into the skin, a small-bore 25G needle is recommended. This type of injection is used primarily to administer antigens to evaluate reactions for allergy or sensitivity studies. A 20G needle is usually used for I.M. injections of oilbased medications; a 22G needle for I.M. injections; and a 25G needle, for I.M. injections; and a 25G needle, for subcutaneous insulin injections. 26. A. Parenteral penicillin can be administered I.M. or added to a solution and given I.V. It cannot be administered subcutaneously or intradermally. 27. D. gr 10 x 60mg/gr 1 = 600 mg 28. C. 100ml/60 min X 15 gtt/ 1 ml = 25 gtt/minute 29. A. Hemoglobinuria, the abnormal presence of hemoglobin in the urine, indicates a hemolytic reaction (incompatibility of the donors and recipients blood). In this reaction, antibodies in the recipients plasma combine rapidly with donor RBCs; the cells are hemolyzed in either circulatory or reticuloendothelial system. Hemolysis occurs more rapidly in ABO incompatibilities than in Rh incompatibilities. Chest pain and urticaria may be symptoms of impending anaphylaxis. Distended neck veins are an indication of hypervolemia. 30. C. In real failure, the kidney loses their ability to effectively eliminate wastes and fluids. Because of this, limiting the patients intake of oral and I.V. fluids may be necessary. Fever, chronic obstructive pulmonary disease, and dehydration are conditions for which fluids should be encouraged. 31. D. Phlebitis, the inflammation of a vein, can be caused by chemical irritants (I.V. solutions or medications), mechanical irritants (the needle or catheter used during venipuncture or cannulation), or a localized allergic reaction to the needle or catheter. Signs and symptoms of phlebitis include pain or discomfort, edema and heat at the I.V. insertion site, and a red streak going up the arm or leg from the I.V. insertion site. 32. D. Return demonstration provides the most certain evidence for evaluating the effectiveness of patient teaching.

33. D. Capsules, enteric-coated tablets, and most extended duration or sustained release products should not be dissolved for use in a gastrostomy tube. They are pharmaceutically manufactured in these forms for valid reasons, and altering them destroys their purpose. The nurse should seek an alternate physicians order when an ordered medication is inappropriate for delivery by tube. 34. D. A drug-allergy is an adverse reaction resulting from an immunologic response following a previous sensitizing exposure to the drug. The reaction can range from a rash or hives to anaphylactic shock. Tolerance to a drug means that the patient experiences a decreasing physiologic response to repeated administration of the drug in the same dosage. Idiosyncrasy is an individuals unique hypersensitivity to a drug, food, or other substance; it appears to be genetically determined. Synergism, is a drug interaction in which the sum of the drugs combined effects is greater than that of their separate effects. 35. D. A hemoglobin and hematocrit count would be ordered by the physician if bleeding were suspected. The other answers are appropriate nursing interventions for a patient who has undergone femoral arteriography. 36. A. Coughing, a protective response that clears the respiratory tract of irritants, usually is involuntary; however it can be voluntary, as when a patient is taught to perform coughing exercises. An antitussive drug inhibits coughing. Splinting the abdomen supports the abdominal muscles when a patient coughs. 37. C. In an infected patient, shivering results from the bodys attempt to increase heat production and the production of neutrophils and phagocytotic action through increased skeletal muscle tension and contractions. Initial vasoconstriction may cause skin to feel cold to the touch. Applying additional bed clothes helps to equalize the body temperature and stop the chills. Attempts to cool the body result in further shivering, increased metabloism, and thus increased heat production. 38. D. A clinical nurse specialist must have completed a masters degree in a clinical specialty and be a registered professional nurse. The National League of Nursing accredits educational programs in nursing and provides a testing service to evaluate student nursing competence but it does not certify nurses. The American Nurses Association identifies requirements for certification and offers examinations for certification in many areas of nursing., such as medical surgical nursing. These certification (credentialing) demonstrates that the nurse has the knowledge and the ability to provide high quality nursing care in the area of her certification. A graduate of an associate degree program is not a clinical nurse specialist: however, she is prepared to provide bed side nursing with a high degree of knowledge and skill. She must successfully complete the licensing examination to become a registered professional nurse.

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39. D. Microorganisms usually do not grow in an acidic environment. 40. D. Bile colors the stool brown. Any inflammation or obstruction that impairs bile flow will affect the stool pigment, yielding light, claycolored stool. Upper GI bleeding results in black or tarry stool. Constipation is characterized by small, hard masses. Many medications and foods will discolor stool for example, drugs containing iron turn stool black.; beets turn stool red. 41. D. In the evaluation step of the nursing process, the nurse must decide whether the patient has achieved the expected outcome that was identified in the planning phase. 42. A. The main sources of vitamin A are yellow and green vegetables (such as carrots, sweet potatoes, squash, spinach, collard greens, broccoli, and cabbage) and yellow fruits (such as apricots, and cantaloupe). Animal sources include liver, kidneys, cream, butter, and egg yolks. 43. D. Maintaing the drainage tubing and collection bag level with the patients bladder could result in reflux of urine into the kidney. Irrigating the bladder with Neosporin and clamping the catheter for 1 hour every 4 hours must be prescribed by a physician. 44. D. The ELISA test of venous blood is used to assess blood and potential blood donors to human immunodeficiency virus (HIV). A positive ELISA test combined with various signs and symptoms helps to diagnose acquired immunodeficiency syndrome (AIDS) 45. D. Tachypnea (an abnormally rapid rate of breathing) would indicate that the patient was still hypoxic (deficient in oxygen).The partial pressures of arterial oxygen and carbon dioxide listed are within the normal range. Eupnea refers to normal respiration. 46. D. Studies have shown that showering with an antiseptic soap before surgery is the most effective method of removing microorganisms from the skin. Shaving the site of the intended surgery might cause breaks in the skin, thereby increasing the risk of infection; however, if indicated, shaving, should be done immediately before surgery, not the day before. A topical antiseptic would not remove microorganisms and would be beneficial only after proper cleaning and rinsing. Tub bathing might transfer organisms to another body site rather than rinse them away. 47. C. The leg muscles are the strongest muscles in the body and should bear the greatest stress when lifting. Muscles of the abdomen, back, and upper arms may be easily injured. 48. C. The factors, known as Virchows triad, collectively predispose a patient to thromboplebitis; impaired venous return to the heart, blood hypercoagulability, and injury to a blood vessel wall. Increased

partial thromboplastin time indicates a prolonged bleeding time during fibrin clot formation, commonly the result of anticoagulant (heparin) therapy. Arterial blood disorders (such as pulsus paradoxus) and lung diseases (such as COPD) do not necessarily impede venous return of injure vessel walls. 49. A. Because of restricted respiratory movement, a recumbent, immobilize patient is at particular risk for respiratory acidosis from poor gas exchange; atelectasis from reduced surfactant and accumulated mucus in the bronchioles, and hypostatic pneumonia from bacterial growth caused by stasis of mucus secretions. 50. B. The immobilized patient commonly suffers from urine retention caused by decreased muscle tone in the perineum. This leads to bladder distention and urine stagnation, which provide an excellent medium for bacterial growth leading to infection. Immobility also results in more alkaline urine with excessive amounts of calcium, sodium and phosphate, a gradual decrease in urine production, and an increased specific gravity. Nursing Practice I -Foundation of Professional Nursing Practice 1. The nurse In-charge in labor and delivery unit administered a dose of terbutaline to a client without checking the clients pulse. The standard that would be used to determine if the nurse was negligent is: a. The physicians orders. b. The action of a clinical nurse specialist who is recognized expert in the field. c. The statement in the drug literature about administration of terbutaline. d. The actions of a reasonably prudent nurse with similar education and experience. 2. Nurse Trish is caring for a female client with a history of GI bleeding, sickle cell disease, and a platelet count of 22,000/l. The female client is dehydrated and receiving dextrose 5% in halfnormal saline solution at 150 ml/hr. The client complains of severe bone pain and is scheduled to receive a dose of morphine sulfate. In administering the medication, Nurse Trish should avoid which route? a. I.V b. I.M c. Oral d. S.C 3. Dr. Garcia writes the following order for the client who has been recently admitted Digoxin .125 mg P.O. once daily. To prevent a dosage error, how should the nurse document this order onto the medication administration record? a. Digoxin .1250 mg P.O. once daily b. Digoxin 0.1250 mg P.O. once daily

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c. Digoxin 0.125 mg P.O. once daily d. Digoxin .125 mg P.O. once daily 4. A newly admitted female client was diagnosed with deep vein thrombosis. Which nursing diagnosis should receive the highest priority? a. Ineffective peripheral tissue perfusion related to venous congestion. b. Risk for injury related to edema. c. Excess fluid volume related to peripheral vascular disease. d. Impaired gas exchange related to increased blood flow. 5. Nurse Betty is assigned to the following clients. The client that the nurse would see first after endorsement? a. A 34 year-old post operative appendectomy client of five hours who is complaining of pain. b. A 44 year-old myocardial infarction (MI) client who is complaining of nausea. c. A 26 year-old client admitted for dehydration whose intravenous (IV) has infiltrated. d. A 63 year-old post operatives abdominal hysterectomy client of three days whose incisional dressing is saturated with serosanguinous fluid. 6. Nurse Gail places a client in a four-point restraint following orders from the physician. The client care plan should include: a. Assess temperature frequently. b. Provide diversional activities. c. Check circulation every 15-30 minutes. d. Socialize with other patients once a shift. 7. A male client who has severe burns is receiving H2 receptor antagonist therapy. The nurse In-charge knows the purpose of this therapy is to: a. Prevent stress ulcer b. Block prostaglandin synthesis c. Facilitate protein synthesis. d. Enhance gas exchange 8. The doctor orders hourly urine output measurement for a postoperative male client. The nurse Trish records the following amounts of output for 2 consecutive hours: 8 a.m.: 50 ml; 9 a.m.: 60 ml. Based on these amounts, which action should the nurse take? a. Increase the I.V. fluid infusion rate b. Irrigate the indwelling urinary catheter c. Notify the physician d. Continue to monitor and record hourly urine output 9. Tony, a basketball player twist his right ankle while playing on the court and seeks care for ankle pain and swelling. After the nurse applies

ice to the ankle for 30 minutes, which statement by Tony suggests that ice application has been effective? a. My ankle looks less swollen now. b. My ankle feels warm. c. My ankle appears redder now. d. I need something stronger for pain relief 10.The physician prescribes a loop diuretic for a client. When administering this drug, the nurse anticipates that the client may develop which electrolyte imbalance? a. Hypernatremia b. Hyperkalemia c. Hypokalemia d. Hypervolemia 11.She finds out that some managers have benevolent-authoritative style of management. Which of the following behaviors will she exhibit most likely? a. Have condescending trust and confidence in their subordinates. b. Gives economic and ego awards. c. Communicates downward to staffs. d. Allows decision making among subordinates. 12. Nurse Amy is aware that the following is true about functional nursing a. Provides continuous, coordinated and comprehensive nursing services. b. One-to-one nurse patient ratio. c. Emphasize the use of group collaboration. d. Concentrates on tasks and activities. 13.Which type of medication order might read "Vitamin K 10 mg I.M. daily 3 days?" a. Single order b. Standard written order c. Standing order d. Stat order 14.A female client with a fecal impaction frequently exhibits which clinical manifestation? a. Increased appetite b. Loss of urge to defecate c. Hard, brown, formed stools d. Liquid or semi-liquid stools 15.Nurse Linda prepares to perform an otoscopic examination on a female client. For proper visualization, the nurse should position the client's ear by: a. Pulling the lobule down and back b. Pulling the helix up and forward c. Pulling the helix up and back d. Pulling the lobule down and forward

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16. Which instruction should nurse Tom give to a male client who is having external radiation therapy: a. Protect the irritated skin from sunlight. b. Eat 3 to 4 hours before treatment. c. Wash the skin over regularly. d. Apply lotion or oil to the radiated area when it is red or sore. 17.In assisting a female client for immediate surgery, the nurse In-charge is aware that she should: a. Encourage the client to void following preoperative medication. b. Explore the clients fears and anxieties about the surgery. c. Assist the client in removing dentures and nail polish. d. Encourage the client to drink water prior to surgery. 18. A male client is admitted and diagnosed with acute pancreatitis after a holiday celebration of excessive food and alcohol. Which assessment finding reflects this diagnosis? a. Blood pressure above normal range. b. Presence of crackles in both lung fields. c. Hyperactive bowel sounds d. Sudden onset of continuous epigastric and back pain. 19. Which dietary guidelines are important for nurse Oliver to implement in caring for the client with burns? a. Provide b. Provide c. Monitor d. Provide high-fiber, high-fat diet high-protein, high-carbohydrate diet. intake to prevent weight gain. ice chips or water intake.

22.A male client is being transferred to the nursing unit for admission after receiving a radium implant for bladder cancer. The nurse incharge would take which priority action in the care of this client? a. Place client on reverse isolation. b. Admit the client into a private room. c. Encourage the client to take frequent rest periods. d. Encourage family and friends to visit. 23.A newly admitted female client was diagnosed with agranulocytosis. The nurse formulates which priority nursing diagnosis? a. Constipation b. Diarrhea c. Risk for infection d. Deficient knowledge 24.A male client is receiving total parenteral nutrition suddenly demonstrates signs and symptoms of an air embolism. What is the priority action by the nurse? a. Notify the physician. b. Place the client on the left side in the Trendelenburg position. c. Place the client in high-Fowlers position. d. Stop the total parenteral nutrition. 25.Nurse May attends an educational conference on leadership styles. The nurse is sitting with a nurse employed at a large trauma center who states that the leadership style at the trauma center is task-oriented and directive. The nurse determines that the leadership style used at the trauma center is: a. Autocratic. b. Laissez-faire. c. Democratic. d. Situational 26.The physician orders DS 500 cc with KCl 10 mEq/liter at 30 cc/hr. The nurse in-charge is going to hang a 500 cc bag. KCl is supplied 20 mEq/10 cc. How many ccs of KCl will be added to the IV solution? a. .5 cc b. 5 cc c. 1.5 cc d. 2.5 cc 27.A child of 10 years old is to receive 400 cc of IV fluid in an 8 hour shift. The IV drip factor is 60. The IV rate that will deliver this amount is: a. 50 cc/ hour b. 55 cc/ hour c. 24 cc/ hour d. 66 cc/ hour

20.Nurse Hazel will administer a unit of whole blood, which priority information should the nurse have about the client? a. Blood pressure and pulse rate. b. Height and weight. c. Calcium and potassium levels d. Hgb and Hct levels. 21. Nurse Michelle witnesses a female client sustain a fall and suspects that the leg may be broken. The nurse takes which priority action? a. Takes a set of vital signs. b. Call the radiology department for X-ray. c. Reassure the client that everything will be alright. d. Immobilize the leg before moving the client.

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28.The nurse is aware that the most important nursing action when a client returns from surgery is: a. Assess the IV for type of fluid and rate of flow. b. Assess the client for presence of pain. c. Assess the Foley catheter for patency and urine output d. Assess the dressing for drainage. 29. Which of the following vital sign assessments that may indicate cardiogenic shock after myocardial infarction? a. BP 80/60, Pulse 110 irregular b. BP 90/50, Pulse 50 regular c. BP 130/80, Pulse 100 regular d. BP 180/100, Pulse 90 irregular 30.Which is the most appropriate nursing action in obtaining a blood pressure measurement? a. Take the proper equipment, place the client in a comfortable position, and record the appropriate information in the clients chart. b. Measure the clients arm, if you are not sure of the size of cuff to use. c. Have the client recline or sit comfortably in a chair with the forearm at the level of the heart. d. Document the measurement, which extremity was used, and the position that the client was in during the measurement. 31.Asking the questions to determine if the person understands the health teaching provided by the nurse would be included during which step of the nursing process? a. Assessment b. Evaluation c. Implementation d. Planning and goals 32.Which of the following item is considered the single most important factor in assisting the health professional in arriving at a diagnosis or determining the persons needs? a. Diagnostic test results b. Biographical date c. History of present illness d. Physical examination 33.In preventing the development of an external rotation deformity of the hip in a client who must remain in bed for any period of time, the most appropriate nursing action would be to use: a. Trochanter roll extending from the crest of the ileum to the midthigh. b. Pillows under the lower legs. c. Footboard d. Hip-abductor pillow

34.Which stage of pressure ulcer development does the ulcer extend into the subcutaneous tissue? a. Stage I b. Stage II c. Stage III d. Stage IV 35.When the method of wound healing is one in which wound edges are not surgically approximated and integumentary continuity is restored by granulations, the wound healing is termed a. Second intention healing b. Primary intention healing c. Third intention healing d. First intention healing 36.An 80-year-old male client is admitted to the hospital with a diagnosis of pneumonia. Nurse Oliver learns that the client lives alone and hasnt been eating or drinking. When assessing him for dehydration, nurse Oliver would expect to find: a. Hypothermia b. Hypertension c. Distended neck veins d. Tachycardia 37.The physician prescribes meperidine (Demerol), 75 mg I.M. every 4 hours as needed, to control a clients postoperative pain. The package insert is Meperidine, 100 mg/ml. How many milliliters of meperidine should the client receive? a. 0.75 b. 0.6 c. 0.5 d. 0.25 38. A male client with diabetes mellitus is receiving insulin. Which statement correctly describes an insulin unit? a. Its a common measurement in the metric system. b. Its the basis for solids in the avoirdupois system. c. Its the smallest measurement in the apothecary system. d. Its a measure of effect, not a standard measure of weight or quantity. 39.Nurse Oliver measures a clients temperature at 102 F. What is the equivalent Centigrade temperature? a. 40.1 C b. 38.9 C c. 48 C d. 38 C

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40.The nurse is assessing a 48-year-old client who has come to the physicians office for his annual physical exam. One of the first physical signs of aging is: a. Accepting limitations while developing assets. b. Increasing loss of muscle tone. c. Failing eyesight, especially close vision. d. Having more frequent aches and pains. 41.The physician inserts a chest tube into a female client to treat a pneumothorax. The tube is connected to water-seal drainage. The nurse in-charge can prevent chest tube air leaks by: a. Checking and taping all connections. b. Checking patency of the chest tube. c. Keeping the head of the bed slightly elevated. d. Keeping the chest drainage system below the level of the chest. 42.Nurse Trish must verify the clients identity before administering medication. She is aware that the safest way to verify identity is to: a. Check the clients identification band. b. Ask the client to state his name. c. State the clients name out loud and wait a client to repeat it. d. Check the room number and the clients name on the bed. 43.The physician orders dextrose 5 % in water, 1,000 ml to be infused over 8 hours. The I.V. tubing delivers 15 drops/ml. Nurse John should run the I.V. infusion at a rate of: a. 30 drops/minute b. 32 drops/minute c. 20 drops/minute d. 18 drops/minute 44.If a central venous catheter becomes disconnected accidentally, what should the nurse in-charge do immediately? a. Clamp the catheter b. Call another nurse c. Call the physician d. Apply a dry sterile dressing to the site. 45.A female client was recently admitted. She has fever, weight loss, and watery diarrhea is being admitted to the facility. While assessing the client, Nurse Hazel inspects the clients abdomen and notice that it is slightly concave. Additional assessment should proceed in which order: a. Palpation, auscultation, and percussion. b. Percussion, palpation, and auscultation. c. Palpation, percussion, and auscultation. d. Auscultation, percussion, and palpation.

46. Nurse Betty is assessing tactile fremitus in a client with pneumonia. For this examination, nurse Betty should use the: a. Fingertips b. Finger pads c. Dorsal surface of the hand d. Ulnar surface of the hand 47. Which type of evaluation occurs continuously throughout the teaching and learning process? a. Summative b. Informative c. Formative d. Retrospective 48.A 45 year old client, has no family history of breast cancer or other risk factors for this disease. Nurse John should instruct her to have mammogram how often? a. Twice per year b. Once per year c. Every 2 years d. Once, to establish baseline 49.A male client has the following arterial blood gas values: pH 7.30; Pao2 89 mmHg; Paco2 50 mmHg; and HCO3 26mEq/L. Based on these values, Nurse Patricia should expect which condition? a. Respiratory acidosis b. Respiratory alkalosis c. Metabolic acidosis d. Metabolic alkalosis 50.Nurse Len refers a female client with terminal cancer to a local hospice. What is the goal of this referral? a. To help the client find appropriate treatment options. b. To provide support for the client and family in coping with terminal illness. c. To ensure that the client gets counseling regarding health care costs. d. To teach the client and family about cancer and its treatment. 51.When caring for a male client with a 3-cm stage I pressure ulcer on the coccyx, which of the following actions can the nurse institute independently? a. Massaging the area with an astringent every 2 hours. b. Applying an antibiotic cream to the area three times per day. c. Using normal saline solution to clean the ulcer and applying a protective dressing as necessary. d. Using a povidone-iodine wash on the ulceration three times per day.

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52.Nurse Oliver must apply an elastic bandage to a clients ankle and calf. He should apply the bandage beginning at the clients: a. Knee b. Ankle c. Lower thigh d. Foot 53.A 10 year old child with type 1 diabetes develops diabetic ketoacidosis and receives a continuous insulin infusion. Which condition represents the greatest risk to this child? a. Hypernatremia b. Hypokalemia c. Hyperphosphatemia d. Hypercalcemia 54.Nurse Len is administering sublingual nitrglycerin (Nitrostat) to the newly admitted client. Immediately afterward, the client may experience: a. Throbbing headache or dizziness b. Nervousness or paresthesia. c. Drowsiness or blurred vision. d. Tinnitus or diplopia. 55.Nurse Michelle hears the alarm sound on the telemetry monitor. The nurse quickly looks at the monitor and notes that a client is in a ventricular tachycardia. The nurse rushes to the clients room. Upon reaching the clients bedside, the nurse would take which action first? a. Prepare for cardioversion b. Prepare to defibrillate the client c. Call a code d. Check the clients level of consciousness 56.Nurse Hazel is preparing to ambulate a female client. The best and the safest position for the nurse in assisting the client is to stand: a. On the unaffected side of the client. b. On the affected side of the client. c. In front of the client. d. Behind the client. 57.Nurse Janah is monitoring the ongoing care given to the potential organ donor who has been diagnosed with brain death. The nurse determines that the standard of care had been maintained if which of the following data is observed? a. Urine output: 45 ml/hr b. Capillary refill: 5 seconds c. Serum pH: 7.32 d. Blood pressure: 90/48 mmHg 58. Nurse Amy has an order to obtain a urinalysis from a male client with an indwelling urinary

catheter. The nurse avoids which of the following, which contaminate the specimen? a. Wiping the port with an alcohol swab before inserting the syringe. b. Aspirating a sample from the port on the drainage bag. c. Clamping the tubing of the drainage bag. d. Obtaining the specimen from the urinary drainage bag. 59.Nurse Meredith is in the process of giving a client a bed bath. In the middle of the procedure, the unit secretary calls the nurse on the intercom to tell the nurse that there is an emergency phone call. The appropriate nursing action is to: a. Immediately walk out of the clients room and answer the phone call. b. Cover the client, place the call light within reach, and answer the phone call. c. Finish the bed bath before answering the phone call. d. Leave the clients door open so the client can be monitored and the nurse can answer the phone call. 60. Nurse Janah is collecting a sputum specimen for culture and sensitivity testing from a client who has a productive cough. Nurse Janah plans to implement which intervention to obtain the specimen? a. Ask the client to expectorate a small amount of sputum into the emesis basin. b. Ask the client to obtain the specimen after breakfast. c. Use a sterile plastic container for obtaining the specimen. d. Provide tissues for expectoration and obtaining the specimen. 61. Nurse Ron is observing a male client using a walker. The nurse determines that the client is using the walker correctly if the client: a. Puts all the four points of the walker flat on the floor, puts weight on the hand pieces, and then walks into it. b. Puts weight on the hand pieces, moves the walker forward, and then walks into it. c. Puts weight on the hand pieces, slides the walker forward, and then walks into it. d. Walks into the walker, puts weight on the hand pieces, and then puts all four points of the walker flat on the floor. 62.Nurse Amy has documented an entry regarding client care in the clients medical record. When checking the entry, the nurse realizes that incorrect information was documented. How does the nurse correct this error? a. Erases the error and writes in the correct information. b. Uses correction fluid to cover up the incorrect

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information and writes in the correct information. c. Draws one line to cross out the incorrect information and then initials the change. d. Covers up the incorrect information completely using a black pen and writes in the correct information 63.Nurse Ron is assisting with transferring a client from the operating room table to a stretcher. To provide safety to the client, the nurse should: a. Moves the client rapidly from the table to the stretcher. b. Uncovers the client completely before transferring to the stretcher. c. Secures the client safety belts after transferring to the stretcher. d. Instructs the client to move self from the table to the stretcher. 64.Nurse Myrna is providing instructions to a nursing assistant assigned to give a bed bath to a client who is on contact precautions. Nurse Myrna instructs the nursing assistant to use which of the following protective items when giving bed bath? a. Gown and goggles b. Gown and gloves c. Gloves and shoe protectors d. Gloves and goggles 65. Nurse Oliver is caring for a client with impaired mobility that occurred as a result of a stroke. The client has right sided arm and leg weakness. The nurse would suggest that the client use which of the following assistive devices that would provide the best stability for ambulating? a. Crutches b. Single straight-legged cane c. Quad cane d. Walker 66.A male client with a right pleural effusion noted on a chest X-ray is being prepared for thoracentesis. The client experiences severe dizziness when sitting upright. To provide a safe environment, the nurse assists the client to which position for the procedure? a. Prone with head turned toward the side supported by a pillow. b. Sims position with the head of the bed flat. c. Right side-lying with the head of the bed elevated 45 degrees. d. Left side-lying with the head of the bed elevated 45 degrees. 67.Nurse John develops methods for data gathering. Which of the following criteria of a good instrument refers to the ability of the instrument to yield the same results upon its repeated administration?

a. Validity b. Specificity c. Sensitivity d. Reliability 68.Harry knows that he has to protect the rights of human research subjects. Which of the following actions of Harry ensures anonymity? a. Keep the identities of the subject secret b. Obtain informed consent c. Provide equal treatment to all the subjects of the study. d. Release findings only to the participants of the study 69.Patients refusal to divulge information is a limitation because it is beyond the control of Tifanny. What type of research is appropriate for this study? a. Descriptive- correlational b. Experiment c. Quasi-experiment d. Historical 70.Nurse Ronald is aware that the best tool for data gathering is? a. Interview schedule b. Questionnaire c. Use of laboratory data d. Observation 71.Monica is aware that there are times when only manipulation of study variables is possible and the elements of control or randomization are not attendant. Which type of research is referred to this? a. Field study b. Quasi-experiment c. Solomon-Four group design d. Post-test only design 72.Cherry notes down ideas that were derived from the description of an investigation written by the person who conducted it. Which type of reference source refers to this? a. Footnote b. Bibliography c. Primary source d. Endnotes 73.When Nurse Trish is providing care to his patient, she must remember that her duty is bound not to do doing any action that will cause the patient harm. This is the meaning of the bioethical principle: a. Non-maleficence b. Beneficence c. Justice d. Solidarity

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74.When a nurse in-charge causes an injury to a female patient and the injury caused becomes the proof of the negligent act, the presence of the injury is said to exemplify the principle of: a. Force majeure b. Respondeat superior c. Res ipsa loquitor d. Holdover doctrine 75.Nurse Myrna is aware that the Board of Nursing has quasi-judicial power. An example of this power is: a. The Board can issue rules and regulations that will govern the practice of nursing b. The Board can investigate violations of the nursing law and code of ethics c. The Board can visit a school applying for a permit in collaboration with CHED d. The Board prepares the board examinations 76. When the license of nurse Krina is revoked, it means that she: a. Is no longer allowed to practice the profession for the rest of her life b. Will never have her/his license re-issued since it has been revoked c. May apply for re-issuance of his/her license based on certain conditions stipulated in RA 9173 d. Will remain unable to practice professional nursing 77.Ronald plans to conduct a research on the use of a new method of pain assessment scale. Which of the following is the second step in the conceptualizing phase of the research process? a. Formulating the research hypothesis b. Review related literature c. Formulating and delimiting the research problem d. Design the theoretical and conceptual framework 78. The leader of the study knows that certain patients who are in a specialized research setting tend to respond psychologically to the conditions of the study. This referred to as : a. Cause and effect b. Hawthorne effect c. Halo effect d. Horns effect 79.Mary finally decides to use judgment sampling on her research. Which of the following actions of is correct? a. Plans to include whoever is there during his study. b. Determines the different nationality of patients frequently admitted and decides to get representations samples from each.

c. Assigns numbers for each of the patients, place these in a fishbowl and draw 10 from it. d. Decides to get 20 samples from the admitted patients 80. The nursing theorist who developed transcultural nursing theory is: a. Florence Nightingale b. Madeleine Leininger c. Albert Moore d. Sr. Callista Roy 81.Marion is aware that the sampling method that gives equal chance to all units in the population to get picked is: a. Random b. Accidental c. Quota d. Judgment 82.John plans to use a Likert Scale to his study to determine the: a. Degree of agreement and disagreement b. Compliance to expected standards c. Level of satisfaction d. Degree of acceptance 83.Which of the following theory addresses the four modes of adaptation? a. Madeleine Leininger b. Sr. Callista Roy c. Florence Nightingale d. Jean Watson 84.Ms. Garcia is responsible to the number of personnel reporting to her. This principle refers to: a. Span of control b. Unity of command c. Downward communication d. Leader 85.Ensuring that there is an informed consent on the part of the patient before a surgery is done, illustrates the bioethical principle of: a. Beneficence b. Autonomy c. Veracity d. Non-maleficence 86.Nurse Reese is teaching a female client with peripheral vascular disease about foot care; Nurse Reese should include which instruction? a. Avoid wearing cotton socks. b. Avoid using a nail clipper to cut toenails. c. Avoid wearing canvas shoes. d. Avoid using cornstarch on feet.

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priority when caring for a newly admitted client who's receiving a blood transfusion? 87.A client is admitted with multiple pressure ulcers. When developing the client's diet plan, the nurse should include: a. Fresh orange slices b. Steamed broccoli c. Ice cream d. Ground beef patties 88.The nurse prepares to administer a cleansing enema. What is the most common client position used for this procedure? a. Lithotomy b. Supine c. Prone d. Sims left lateral 89.Nurse Marian is preparing to administer a blood transfusion. Which action should the nurse take first? a. Arrange for typing and cross matching of the clients blood. b. Compare the clients identification wristband with the tag on the unit of blood. c. Start an I.V. infusion of normal saline solution. d. Measure the clients vital signs. 90.A 65 years old male client requests his medication at 9 p.m. instead of 10 p.m. so that he can go to sleep earlier. Which type of nursing intervention is required? a. Independent b. Dependent c. Interdependent d. Intradependent 91.A female client is to be discharged from an acute care facility after treatment for right leg thrombophlebitis. The Nurse Betty notes that the client's leg is pain-free, without redness or edema. The nurse's actions reflect which step of the nursing process? a. Assessment b. Diagnosis c. Implementation d. Evaluation 92.Nursing care for a female client includes removing elastic stockings once per day. The Nurse Betty is aware that the rationale for this intervention? a. To increase blood flow to the heart b. To observe the lower extremities c. To allow the leg muscles to stretch and relax d. To permit veins in the legs to fill with blood. 93.Which nursing intervention takes highest a. Instructing the client to report any itching, swelling, or dyspnea. b. Informing the client that the transfusion usually take 1 to 2 hours. c. Documenting blood administration in the client care record. d. Assessing the clients vital signs when the transfusion ends. 94.A male client complains of abdominal discomfort and nausea while receiving tube feedings. Which intervention is most appropriate for this problem? a. Give the feedings at room temperature. b. Decrease the rate of feedings and the concentration of the formula. c. Place the client in semi-Fowler's position while feeding. d. Change the feeding container every 12 hours. 95.Nurse Patricia is reconstituting a powdered medication in a vial. After adding the solution to the powder, she nurse should: a. Do nothing. b. Invert the vial and let it stand for 3 to 5 minutes. c. Shake the vial vigorously. d. Roll the vial gently between the palms. 96.Which intervention should the nurse Trish use when administering oxygen by face mask to a female client? a. Secure the elastic band tightly around the client's head. b. Assist the client to the semi-Fowler position if possible. c. Apply the face mask from the client's chin up over the nose. d. Loosen the connectors between the oxygen equipment and humidifier. 97.The maximum transfusion time for a unit of packed red blood cells (RBCs) is: a. 6 hours b. 4 hours c. 3 hours d. 2 hours 98.Nurse Monique is monitoring the effectiveness of a client's drug therapy. When should the nurse Monique obtain a blood sample to measure the trough drug level? a. 1 hour before administering the next dose. b. Immediately before administering the next dose. c. Immediately after administering the next dose. d. 30 minutes after administering the next dose.

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99.Nurse May is aware that the main advantage of using a floor stock system is: a. The nurse can implement medication orders quickly. b. The nurse receives input from the pharmacist. c. The system minimizes transcription errors. d. The system reinforces accurate calculations. 100. Nurse Oliver is assessing a client's abdomen. Which finding should the nurse report as abnormal? a. Dullness over the liver. b. Bowel sounds occurring every 10 seconds. c. Shifting dullness over the abdomen. d. Vascular sounds heard over the renal arteries. Nursing Practice I -Foundation of Professional Nursing Practice- Answer 1. Answer: (D) The actions of a reasonably prudent nurse with similar education and experience. Rationale: The standard of care is determined by the average degree of skill, care, and diligence by nurses in similar circumstances. 2. Answer: (B) I.M Rationale: With a platelet count of 22,000/l, the clients tends to bleed easily. Therefore, the nurse should avoid using the I.M. route because the area is a highly vascular and can bleed readily when penetrated by a needle. The bleeding can be difficult to stop. 3. Answer: (C) Digoxin 0.125 mg P.O. once daily Rationale: The nurse should always place a zero before a decimal point so that no one misreads the figure, which could result in a dosage error. The nurse should never insert a zero at the end of a dosage that includes a decimal point because this could be misread, possibly leading to a tenfold increase in the dosage. 4. Answer: (A) Ineffective peripheral tissue perfusion related to venous congestion. Rationale: Ineffective peripheral tissue perfusion related to venous congestion takes the highest priority because venous inflammation and clot formation impede blood flow in a client with deep vein thrombosis. 5. Answer: (B) A 44 year-old myocardial infarction (MI) client who is complaining of nausea. Rationale: Nausea is a symptom of impending myocardial infarction (MI) and should be assessed immediately so that treatment can be instituted and further damage to the heart is avoided. 6. Answer: (C) Check circulation every 15-30 minutes. Rationale: Restraints encircle the limbs, which

place the client at risk for circulation being restricted to the distal areas of the extremities. Checking the clients circulation every 15-30 minutes will allow the nurse to adjust the restraints before injury from decreased blood flow occurs. 7. Answer: (A) Prevent stress ulcer Rationale: Curlings ulcer occurs as a generalized stress response in burn patients. This results in a decreased production of mucus and increased secretion of gastric acid. The best treatment for this prophylactic use of antacids and H2 receptor blockers. 8. Answer: (D) Continue to monitor and record hourly urine output Rationale: Normal urine output for an adult is approximately 1 ml/minute (60 ml/hour). Therefore, this client's output is normal. Beyond continued evaluation, no nursing action is warranted. 9. Answer: (B) My ankle feels warm. Rationale: Ice application decreases pain and swelling. Continued or increased pain, redness, and increased warmth are signs of inflammation that shouldn't occur after ice application 10. Answer: (B) Hyperkalemia Rationale: A loop diuretic removes water and, along with it, sodium and potassium. This may result in hypokalemia, hypovolemia, and hyponatremia. 11. Answer:(A) Have condescending trust and confidence in their subordinates Rationale: Benevolent-authoritative managers pretentiously show their trust and confidence to their followers. 12. Answer: (A) Provides continuous, coordinated and comprehensive nursing services. Rationale: Functional nursing is focused on tasks and activities and not on the care of the patients. 13. Answer: (B) Standard written order Rationale: This is a standard written order. Prescribers write a single order for medications given only once. A stat order is written for medications given immediately for an urgent client problem. A standing order, also known as a protocol, establishes guidelines for treating a particular disease or set of symptoms in special care areas such as the coronary care unit. Facilities also may institute medication protocols that specifically designate drugs that a nurse may not give. 14. Answer: (D) Liquid or semi-liquid stools Rationale: Passage of liquid or semi-liquid stools results from seepage of unformed bowel contents around the impacted stool in the rectum. Clients with fecal impaction don't pass hard, brown, formed stools because the feces can't move past the impaction. These clients typically report the urge to defecate (although they can't pass stool) and a decreased appetite. 15. Answer: (C) Pulling the helix up and back

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Rationale: To perform an otoscopic examination on an adult, the nurse grasps the helix of the ear and pulls it up and back to straighten the ear canal. For a child, the nurse grasps the helix and pulls it down to straighten the ear canal. Pulling the lobule in any direction wouldn't straighten the ear canal for visualization. 16. Answer: (A) Protect the irritated skin from sunlight. Rationale: Irradiated skin is very sensitive and must be protected with clothing or sunblock. The priority approach is the avoidance of strong sunlight. 17. Answer: (C) Assist the client in removing dentures and nail polish. Rationale: Dentures, hairpins, and combs must be removed. Nail polish must be removed so that cyanosis can be easily monitored by observing the nail beds. 18. Answer: (D) Sudden onset of continuous epigastric and back pain. Rationale: The autodigestion of tissue by the pancreatic enzymes results in pain from inflammation, edema, and possible hemorrhage. Continuous, unrelieved epigastric or back pain reflects the inflammatory process in the pancreas. 19. Answer: (B) Provide high-protein, highcarbohydrate diet. Rationale: A positive nitrogen balance is important for meeting metabolic needs, tissue repair, and resistance to infection. Caloric goals may be as high as 5000 calories per day. 20. Answer: (A) Blood pressure and pulse rate. Rationale: The baseline must be established to recognize the signs of an anaphylactic or hemolytic reaction to the transfusion. 21. Answer: (D) Immobilize the leg before moving the client. Rationale: If the nurse suspects a fracture, splinting the area before moving the client is imperative. The nurse should call for emergency help if the client is not hospitalized and call for a physician for the hospitalized client. 22. Answer: (B) Admit the client into a private room. Rationale: The client who has a radiation implant is placed in a private room and has a limited number of visitors. This reduces the exposure of others to the radiation. 23. Answer: (C) Risk for infection Rationale: Agranulocytosis is characterized by a reduced number of leukocytes (leucopenia) and neutrophils (neutropenia) in the blood. The client is at high risk for infection because of the decreased body defenses against microorganisms. Deficient knowledge related to the nature of the disorder may be appropriate diagnosis but is not the priority. 24. Answer: (B) Place the client on the left side in the Trendelenburg position.

Rationale: Lying on the left side may prevent air from flowing into the pulmonary veins. The Trendelenburg position increases intrathoracic pressure, which decreases the amount of blood pulled into the vena cava during aspiration. 25. Answer: (A) Autocratic. Rationale: The autocratic style of leadership is a task-oriented and directive. 26. Answer: (D) 2.5 cc Rationale: 2.5 cc is to be added, because only a 500 cc bag of solution is being medicated instead of a 1 liter. 27. Answer: (A) 50 cc/ hour Rationale: A rate of 50 cc/hr. The child is to receive 400 cc over a period of 8 hours = 50 cc/hr. 28. Answer: (B) Assess the client for presence of pain. Rationale: Assessing the client for pain is a very important measure. Postoperative pain is an indication of complication. The nurse should also assess the client for pain to provide for the clients comfort. 29. Answer: (A) BP 80/60, Pulse 110 irregular Rationale: The classic signs of cardiogenic shock are low blood pressure, rapid and weak irregular pulse, cold, clammy skin, decreased urinary output, and cerebral hypoxia. 30. Answer: (A) Take the proper equipment, place the client in a comfortable position, and record the appropriate information in the clients chart. Rationale: It is a general or comprehensive statement about the correct procedure, and it includes the basic ideas which are found in the other options 31. Answer: (B) Evaluation Rationale: Evaluation includes observing the person, asking questions, and comparing the patients behavioral responses with the expected outcomes. 32. Answer: (C) History of present illness Rationale: The history of present illness is the single most important factor in assisting the health professional in arriving at a diagnosis or determining the persons needs. 33. Answer: (A) Trochanter roll extending from the crest of the ileum to the mid-thigh. Rationale: A trochanter roll, properly placed, provides resistance to the external rotation of the hip. 34. Answer: (C) Stage III Rationale: Clinically, a deep crater or without undermining of adjacent tissue is noted. 35. Answer: (A) Second intention healing Rationale: When wounds dehisce, they will allowed to heal by secondary intention

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36. Answer: (D) Tachycardia Rationale: With an extracellular fluid or plasma volume deficit, compensatory mechanisms stimulate the heart, causing an increase in heart rate. 37. Answer: (A) 0.75 Rationale: To determine the number of milliliters the client should receive, the nurse uses the fraction method in the following equation. 75 mg/X ml = 100 mg/1 ml To solve for X, cross-multiply: 75 mg x 1 ml = X ml x 100 mg 75 = 100X 75/100 = X 0.75 ml (or ml) = X 38. Answer: (D) Its a measure of effect, not a standard measure of weight or quantity. Rationale: An insulin unit is a measure of effect, not a standard measure of weight or quantity. Different drugs measured in units may have no relationship to one another in quality or quantity. 39. Answer: (B) 38.9 C Rationale: To convert Fahrenheit degreed to Centigrade, use this formula C = (F 32) 1.8 C = (102 32) 1.8 C = 70 1.8 C = 38.9 40. Answer: (C) Failing eyesight, especially close vision. Rationale: Failing eyesight, especially close vision, is one of the first signs of aging in middle life (ages 46 to 64). More frequent aches and pains begin in the early late years (ages 65 to 79). Increase in loss of muscle tone occurs in later years (age 80 and older). 41. Answer: (A) Checking and taping all connections Rationale: Air leaks commonly occur if the system isnt secure. Checking all connections and taping them will prevent air leaks. The chest drainage system is kept lower to promote drainage not to prevent leaks. 42. Answer: (A) Check the clients identification band. Rationale: Checking the clients identification band is the safest way to verify a clients identity because the band is assigned on admission and isnt be removed at any time. (If it is removed, it must be replaced). Asking the clients name or having the client repeated his name would be appropriate only for a client whos alert, oriented, and able to understand what is being said, but isnt the safe standard of practice. Names on bed arent always reliable 43. Answer: (B) 32 drops/minute Rationale: Giving 1,000 ml over 8 hours is the same as giving 125 ml over 1 hour (60 minutes). Find the number of milliliters per minute as follows: 125/60 minutes = X/1 minute 60X = 125 = 2.1 ml/minute To find the number of drops per minute:

2.1 ml/X gtt = 1 ml/ 15 gtt X = 32 gtt/minute, or 32 drops/minute 44. Answer: (A) Clamp the catheter Rationale: If a central venous catheter becomes disconnected, the nurse should immediately apply a catheter clamp, if available. If a clamp isnt available, the nurse can place a sterile syringe or catheter plug in the catheter hub. After cleaning the hub with alcohol or povidoneiodine solution, the nurse must replace the I.V. extension and restart the infusion. 45. Answer: (D) Auscultation, percussion, and palpation. Rationale: The correct order of assessment for examining the abdomen is inspection, auscultation, percussion, and palpation. The reason for this approach is that the less intrusive techniques should be performed before the more intrusive techniques. Percussion and palpation can alter natural findings during auscultation. 46. Answer: (D) Ulnar surface of the hand Rationale: The nurse uses the ulnar surface, or ball, of the hand to asses tactile fremitus, thrills, and vocal vibrations through the chest wall. The fingertips and finger pads best distinguish texture and shape. The dorsal surface best feels warmth. 47. Answer: (C) Formative Rationale: Formative (or concurrent) evaluation occurs continuously throughout the teaching and learning process. One benefit is that the nurse can adjust teaching strategies as necessary to enhance learning. Summative, or retrospective, evaluation occurs at the conclusion of the teaching and learning session. Informative is not a type of evaluation. 48. Answer: (B) Once per year Rationale: Yearly mammograms should begin at age 40 and continue for as long as the woman is in good health. If health risks, such as family history, genetic tendency, or past breast cancer, exist, more frequent examinations may be necessary. 49. Answer: (A) Respiratory acidosis Rationale: The client has a below-normal (acidic) blood pH value and an above-normal partial pressure of arterial carbon dioxide (Paco2) value, indicating respiratory acidosis. In respiratory alkalosis, the pH value is above normal and in the Paco2 value is below normal. In metabolic acidosis, the pH and bicarbonate (Hco3) values are below normal. In metabolic alkalosis, the pH and Hco3 values are above normal. 50. Answer: (B) To provide support for the client and family in coping with terminal illness. Rationale: Hospices provide supportive care for terminally ill clients and their families. Hospice care doesnt focus on counseling regarding health care costs. Most client referred to hospices have been treated for their disease without success and will receive only palliative care in the hospice.

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51. Answer: (C) Using normal saline solution to clean the ulcer and applying a protective dressing as necessary. Rationale: Washing the area with normal saline solution and applying a protective dressing are within the nurses realm of interventions and will protect the area. Using a povidone-iodine wash and an antibiotic cream require a physicians order. Massaging with an astringent can further damage the skin. 52. Answer: (D) Foot Rationale: An elastic bandage should be applied form the distal area to the proximal area. This method promotes venous return. In this case, the nurse should begin applying the bandage at the clients foot. Beginning at the ankle, lower thigh, or knee does not promote venous return. 53. Answer: (B) Hypokalemia Rationale: Insulin administration causes glucose and potassium to move into the cells, causing hypokalemia. 54. Answer: (A) Throbbing headache or dizziness Rationale: Headache and dizziness often occur when nitroglycerin is taken at the beginning of therapy. However, the client usually develops tolerance 55. Answer: (D) Check the clients level of consciousness Rationale: Determining unresponsiveness is the first step assessment action to take. When a client is in ventricular tachycardia, there is a significant decrease in cardiac output. However, checking the unresponsiveness ensures whether the client is affected by the decreased cardiac output. 56. Answer: (B) On the affected side of the client. Rationale: When walking with clients, the nurse should stand on the affected side and grasp the security belt in the midspine area of the small of the back. The nurse should position the free hand at the shoulder area so that the client can be pulled toward the nurse in the event that there is a forward fall. The client is instructed to look up and outward rather than at his or her feet. 57. Answer: (A) Urine output: 45 ml/hr Rationale: Adequate perfusion must be maintained to all vital organs in order for the client to remain visible as an organ donor. A urine output of 45 ml per hour indicates adequate renal perfusion. Low blood pressure and delayed capillary refill time are circulatory system indicators of inadequate perfusion. A serum pH of 7.32 is acidotic, which adversely affects all body tissues. 58. Answer: (D ) Obtaining the specimen from the urinary drainage bag. Rationale: A urine specimen is not taken from the urinary drainage bag. Urine undergoes chemical changes while sitting in the bag and does not necessarily reflect the current client status. In addition, it may become contaminated with bacteria from opening the system.

59. Answer: (B) Cover the client, place the call light within reach, and answer the phone call. Rationale: Because telephone call is an emergency, the nurse may need to answer it. The other appropriate action is to ask another nurse to accept the call. However, is not one of the options. To maintain privacy and safety, the nurse covers the client and places the call light within the clients reach. Additionally, the clients door should be closed or the room curtains pulled around the bathing area. 60. Answer: (C) Use a sterile plastic container for obtaining the specimen. Rationale: Sputum specimens for culture and sensitivity testing need to be obtained using sterile techniques because the test is done to determine the presence of organisms. If the procedure for obtaining the specimen is not sterile, then the specimen is not sterile, then the specimen would be contaminated and the results of the test would be invalid. 61. Answer: (A) Puts all the four points of the walker flat on the floor, puts weight on the hand pieces, and then walks into it. Rationale: When the client uses a walker, the nurse stands adjacent to the affected side. The client is instructed to put all four points of the walker 2 feet forward flat on the floor before putting weight on hand pieces. This will ensure client safety and prevent stress cracks in the walker. The client is then instructed to move the walker forward and walk into it. 62. Answer: (C) Draws one line to cross out the incorrect information and then initials the change. Rationale: To correct an error documented in a medical record, the nurse draws one line through the incorrect information and then initials the error. An error is never erased and correction fluid is never used in the medical record. 63. Answer: (C) Secures the client safety belts after transferring to the stretcher. Rationale: During the transfer of the client after the surgical procedure is complete, the nurse should avoid exposure of the client because of the risk for potential heat loss. Hurried movements and rapid changes in the position should be avoided because these predispose the client to hypotension. At the time of the transfer from the surgery table to the stretcher, the client is still affected by the effects of the anesthesia; therefore, the client should not move self. Safety belts can prevent the client from falling off the stretcher. 64. Answer: (B) Gown and gloves Rationale: Contact precautions require the use of gloves and a gown if direct client contact is anticipated. Goggles are not necessary unless the nurse anticipates the splashes of blood, body fluids, secretions, or excretions may occur. Shoe protectors are not necessary. 65. Answer: (C) Quad cane Rationale: Crutches and a walker can be difficult to maneuver for a client with weakness on one side. A cane is better suited for client with

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weakness of the arm and leg on one side. However, the quad cane would provide the most stability because of the structure of the cane and because a quad cane has four legs. 66. Answer: (D) Left side-lying with the head of the bed elevated 45 degrees. Rationale: To facilitate removal of fluid from the chest wall, the client is positioned sitting at the edge of the bed leaning over the bedside table with the feet supported on a stool. If the client is unable to sit up, the client is positioned lying in bed on the unaffected side with the head of the bed elevated 30 to 45 degrees. 67. Answer: (D) Reliability Rationale: Reliability is consistency of the research instrument. It refers to the repeatability of the instrument in extracting the same responses upon its repeated administration. 68. Answer: (A) Keep the identities of the subject secret Rationale: Keeping the identities of the research subject secret will ensure anonymity because this will hinder providing link between the information given to whoever is its source. 69. Answer: (A) Descriptive- correlational Rationale: Descriptive- correlational study is the most appropriate for this study because it studies the variables that could be the antecedents of the increased incidence of nosocomial infection. 70. Answer: (C) Use of laboratory data Rationale: Incidence of nosocomial infection is best collected through the use of biophysiologic measures, particularly in vitro measurements, hence laboratory data is essential. 71. Answer: (B) Quasi-experiment Rationale: Quasi-experiment is done when randomization and control of the variables are not possible. 72. Answer: (C) Primary source Rationale: This refers to a primary source which is a direct account of the investigation done by the investigator. In contrast to this is a secondary source, which is written by someone other than the original researcher. 73. Answer: (A) Non-maleficence Rationale: Non-maleficence means do not cause harm or do any action that will cause any harm to the patient/client. To do good is referred as beneficence. 74. Answer: (C) Res ipsa loquitor Rationale: Res ipsa loquitor literally means the thing speaks for itself. This means in operational terms that the injury caused is the proof that there was a negligent act. 75. Answer: (B) The Board can investigate violations of the nursing law and code of ethics Rationale: Quasi-judicial power means that the Board of Nursing has the authority to investigate violations of the nursing law and can issue summons, subpoena or subpoena duces tecum as

needed. 76. Answer: (C) May apply for re-issuance of his/her license based on certain conditions stipulated in RA 9173 Rationale: RA 9173 sec. 24 states that for equity and justice, a revoked license maybe re-issued provided that the following conditions are met: a) the cause for revocation of license has already been corrected or removed; and, b) at least four years has elapsed since the license has been revoked. 77. Answer: (B) Review related literature Rationale: After formulating and delimiting the research problem, the researcher conducts a review of related literature to determine the extent of what has been done on the study by previous researchers. 78. Answer: (B) Hawthorne effect Rationale: Hawthorne effect is based on the study of Elton Mayo and company about the effect of an intervention done to improve the working conditions of the workers on their productivity. It resulted to an increased productivity but not due to the intervention but due to the psychological effects of being observed. They performed differently because they were under observation. 79. Answer: (B) Determines the different nationality of patients frequently admitted and decides to get representations samples from each. Rationale: Judgment sampling involves including samples according to the knowledge of the investigator about the participants in the study. 80. Answer: (B) Madeleine Leininger Rationale: Madeleine Leininger developed the theory on transcultural theory based on her observations on the behavior of selected people within a culture. 81. Answer: (A) Random Rationale: Random sampling gives equal chance for all the elements in the population to be picked as part of the sample. 82. Answer: (A) Degree of agreement and disagreement Rationale: Likert scale is a 5-point summated scale used to determine the degree of agreement or disagreement of the respondents to a statement in a study 83. Answer: (B) Sr. Callista Roy Rationale: Sr. Callista Roy developed the Adaptation Model which involves the physiologic mode, self-concept mode, role function mode and dependence mode. 84. Answer: (A) Span of control Rationale: Span of control refers to the number of workers who report directly to a manager. 85. Answer: (B) Autonomy Rationale: Informed consent means that the patient fully understands about the surgery, including the risks involved and the alternative

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solutions. In giving consent it is done with full knowledge and is given freely. The action of allowing the patient to decide whether a surgery is to be done or not exemplifies the bioethical principle of autonomy. 86. Answer: (C) Avoid wearing canvas shoes. Rationale: The client should be instructed to avoid wearing canvas shoes. Canvas shoes cause the feet to perspire, which may, in turn, cause skin irritation and breakdown. Both cotton and cornstarch absorb perspiration. The client should be instructed to cut toenails straight across with nail clippers. 87. Answer: (D) Ground beef patties Rationale: Meat is an excellent source of complete protein, which this client needs to repair the tissue breakdown caused by pressure ulcers. Oranges and broccoli supply vitamin C but not protein. Ice cream supplies only some incomplete protein, making it less helpful in tissue repair. 88. Answer: (D) Sims left lateral Rationale: The Sims' left lateral position is the most common position used to administer a cleansing enema because it allows gravity to aid the flow of fluid along the curve of the sigmoid colon. If the client can't assume this position nor has poor sphincter control, the dorsal recumbent or right lateral position may be used. The supine and prone positions are inappropriate and uncomfortable for the client. 89. Answer: (A) Arrange for typing and cross matching of the clients blood. Rationale: The nurse first arranges for typing and cross matching of the client's blood to ensure compatibility with donor blood. The other options, although appropriate when preparing to administer a blood transfusion, come later. 90. Answer: (A) Independent Rationale: Nursing interventions are classified as independent, interdependent, or dependent. Altering the drug schedule to coincide with the client's daily routine represents an independent intervention, whereas consulting with the physician and pharmacist to change a client's medication because of adverse reactions represents an interdependent intervention. Administering an already-prescribed drug on time is a dependent intervention. An intradependent nursing intervention doesn't exist. 91. Answer: (D) Evaluation Rationale: The nursing actions described constitute evaluation of the expected outcomes. The findings show that the expected outcomes have been achieved. Assessment consists of the client's history, physical examination, and laboratory studies. Analysis consists of considering assessment information to derive the appropriate nursing diagnosis. Implementation is the phase of the nursing process where the nurse puts the plan of care into action. 92. Answer: (B) To observe the lower extremities

Rationale: Elastic stockings are used to promote venous return. The nurse needs to remove them once per day to observe the condition of the skin underneath the stockings. Applying the stockings increases blood flow to the heart. When the stockings are in place, the leg muscles can still stretch and relax, and the veins can fill with blood. 93. Answer:(A) Instructing the client to report any itching, swelling, or dyspnea. Rationale: Because administration of blood or blood products may cause serious adverse effects such as allergic reactions, the nurse must monitor the client for these effects. Signs and symptoms of life-threatening allergic reactions include itching, swelling, and dyspnea. Although the nurse should inform the client of the duration of the transfusion and should document its administration, these actions are less critical to the client's immediate health. The nurse should assess vital signs at least hourly during the transfusion. 94. Answer: (B) Decrease the rate of feedings and the concentration of the formula. Rationale: Complaints of abdominal discomfort and nausea are common in clients receiving tube feedings. Decreasing the rate of the feeding and the concentration of the formula should decrease the client's discomfort. Feedings are normally given at room temperature to minimize abdominal cramping. To prevent aspiration during feeding, the head of the client's bed should be elevated at least 30 degrees. Also, to prevent bacterial growth, feeding containers should be routinely changed every 8 to 12 hours. 95. Answer: (D) Roll the vial gently between the palms. Rationale: Rolling the vial gently between the palms produces heat, which helps dissolve the medication. Doing nothing or inverting the vial wouldn't help dissolve the medication. Shaking the vial vigorously could cause the medication to break down, altering its action. 96. Answer: (B) Assist the client to the semiFowler position if possible. Rationale: By assisting the client to the semiFowler position, the nurse promotes easier chest expansion, breathing, and oxygen intake. The nurse should secure the elastic band so that the face mask fits comfortably and snugly rather than tightly, which could lead to irritation. The nurse should apply the face mask from the client's nose down to the chin not vice versa. The nurse should check the connectors between the oxygen equipment and humidifier to ensure that they're airtight; loosened connectors can cause loss of oxygen. 97. Answer: (B) 4 hours Rationale: A unit of packed RBCs may be given over a period of between 1 and 4 hours. It shouldn't infuse for longer than 4 hours because the risk of contamination and sepsis increases after that time. Discard or return to the blood bank any blood not given within this time, according to facility policy.

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98. Answer: (B) Immediately before administering the next dose. Rationale: Measuring the blood drug concentration helps determine whether the dosing has achieved the therapeutic goal. For measurement of the trough, or lowest, blood level of a drug, the nurse draws a blood sample immediately before administering the next dose. Depending on the drug's duration of action and half-life, peak blood drug levels typically are drawn after administering the next dose. 99. Answer: (A) The nurse can implement medication orders quickly. Rationale: A floor stock system enables the nurse to implement medication orders quickly. It doesn't allow for pharmacist input, nor does it minimize transcription errors or reinforce accurate calculations. 100. Answer: (C) Shifting dullness over the abdomen. Rationale: Shifting dullness over the abdomen indicates ascites, an abnormal finding. The other options are normal abdominal findings. Pre-board Exam for November 2009 NLE 1. A pregnant woman who is at term is admitted to the birthing unit in active labor. The client has only progressed from 2cm to 3 cm in 8 hours. She is diagnosed with hypotonic dystocia and the physician ordered Oxytocin (Pitocin) to augment her contractions. Which of the following is the most important aspect of nursing intervention at this time? A) Timing and recording length of contractions. B) Monitoring. C) Preparing for an emergency cesarean birth. D) Checking the perineum for bulging. 2. A client who hallucinates is not in touch with reality. It is important for the nurse to: A) Isolate the client from other patients. B) Maintain a safe environment. C) Orient the client to time, place, and person. D) Establish a trusting relationship. 3. The nurse is caring to a child client who has had a tonsillectomy. The child complains of having dryness of the throat. Which of the following would the nurse give to the child? A) Cola with ice B) Yellow noncitrus Jello C) Cool cherry Kool-Aid D) A glass of milk 4. The physician ordered Phenylephrine (NeoSynephrine) nasal spray to a 13-year-old client. The nurse caring to the client provides instructions that the nasal spray must be used exactly as directed to prevent the development of:

A) Increased nasal congestion. B) Nasal polyps. C) Bleeding tendencies. D) Tinnitus and diplopia. 5. A client with tuberculosis is to be admitted in the hospital. The nurse who will be assigned to care for the client must institute appropriate precautions. The nurse should: A) Place the client in a private room. B) Wear an N 95 respirator when caring for the client. C) Put on a gown every time when entering the room. D) Don a surgical mask with a face shield when entering the room. 6. Which of the following is the most frequent cause of noncompliance to the medical treatment of open-angle glaucoma? A) The frequent nausea and vomiting accompanying use of miotic drug. B) Loss of mobility due to severe driving restrictions. C) Decreased light and near-vision accommodation due to miotic effects of pilocarpine. D) The painful and insidious progression of this type of glaucoma. 7. In the morning shift, the nurse is making rounds in the nursing care units. The nurse enters in a clients room and notes that the clients tube has become disconnected from the Pleurovac. What would be the initial nursing action? A) Apply pressure directly over the incision site. B) Clamp the chest tube near the incision site. C) Clamp the chest tube closer to the drainage system. D) Reconnect the chest tube to the Pleurovac. 8. Which of the following complications during a breech birth the nurse needs to be alarmed? A) Abruption placenta. B) Caput succedaneum. C) Pathological hyperbilirubinemia. D) Umbilical cord prolapse. 9. The nurse is caring to a client diagnosed with severe depression. Which of the following nursing approach is important in depression? A) Protect the client against harm to others. B) Provide the client with motor outlets for aggressive, hostile feelings. C) Reduce interpersonal contacts. D) Deemphasizing preoccupation with elimination, nourishment, and sleep. 10. A 3-month-old client is in the pediatric unit.

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During assessment, the nurse is suspecting that the baby may have hypothyroidism when mother states that her baby does not: A) Sit up. B) Pick up and hold a rattle. C) Roll over. D) Hold the head up. 11. The physician calls the nursing unit to leave an order. The senior nurse had conversation with the other staff. The newly hired nurse answers the phone so that the senior nurses may continue their conversation. The new nurse does not knowthe physician or the client to whom the order pertains. The nurse should: A) Ask the physician to call back after the nurse has read the hospital policy manual. B) Take the telephone order. C) Refuse to take the telephone order. D) Ask the charge nurse or one of the other senior staff nurses to take the telephone order. 12. The staff nurse on the labor and delivery unit is assigned to care to a primigravida in transition complicated by hypertension. A new pregnant woman in active labor is admitted in the same unit. The nurse manager assigned the same nurse to the second client. The nurse feels that the client with hypertension requires one-to-one care. What would be the initial actionof the nurse? A) Accept the new assignment and complete an incident report describing a shortage of nursing staff. B) Report the incident to the nursing supervisor and request to be floated. C) Report the nursing assessment of the client in transitional labor to the nurse manager and discuss misgivings about the new assignment. D) Accept the new assignment and provide the best care. 13. A newborn infant with Down syndrome is to be discharged today. The nurse is preparing to give the discharge teaching regarding the proper care at home. The nurse would anticipate that the mother is probably at the: A) 40 years of age. B) 20 years of age. C) 35 years of age. D) 20 years of age. 14. The emergency department has shortage of staff. The nurse manager informs the staff nurse in the critical care unit that she has to float to the emergency department. What should the staff nurse expect under these conditions? A) The float staff nurse will be informed of the situation before the shift begins. B) The staff nurse will be able to negotiate the assignments in the emergency department. C) Cross training will be available for the staff

nurse. D) Client assignments will be equally divided among the nurses. 15. The nurse is assigned to care for a child client admitted in the pediatrics unit. The client is receiving digoxin. Which of the following questions will be asked by the nurse to the parents of the child in order to assess the clients risk for digoxin toxicity? A) Has he been exposed to any childhood communicable diseases in the past 2-3 weeks? B) Has he been taking diuretics at home? C) Do any of his brothers and sisters have history of cardiac problems? D) Has he been going to school regularly? 16. The nurse noticed that the signed consent form has an error. The form states, Amputation of the right leg instead of the left leg that is to be amputated. The nurse has administered already the preoperative medications. What should the nurse do? A) Call the physician to reschedule the surgery. B) Call the nearest relative to come in to sign a new form. C) Cross out the error and initial the form. D) Have the client sign another form. 17. The nurse in the nursing care unit checks the fluctuation in the water-seal compartment of a closed chest drainage system. The fluctuation has stopped, the nurse would: A) Vigorously strip the tube to dislodge a clot. B) Raise the apparatus above the chest to move fluid. C) Increase wall suction above 20 cm H2O pressure. D) Ask the client to cough and take a deep breath. 18. The pediatric nurse in the neonatal unit was informed that the baby that is brought to the mother in the hospital room is wrong. The nurse determines that two babies were placed in the wrong cribs. The most appropriate nursing action would be to: A) Determine who is responsible for the mistake and terminate his or her employment. B) Record the event in an incident/variance report and notify the nursing supervisor. C) Reassure both mothers, report to the charge nurse, and do not record. D) Record detailed notes of the event on the mothers medical record. 19. Before the administration of digoxin, the nurse completes an assessment to a toddler client for signs and symptoms of digoxin toxicity. Which of the following is the earliest and most significant sign of digoxin toxicity?

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A) Tinnitus B) Nausea and vomiting C) Vision problem D) Slowing in the heart rate 20. Which of the following treatment modality is appropriate for a client with paranoid tendency? A) Activity therapy. B) Individual therapy. C) Group therapy. D) Family therapy. 21. The client with rheumatoid arthritis is for discharge. In preparing the client for discharge on prednisone therapy, the nurse should advise the client to: A) Wear sunglasses if exposed to bright light for an extended period of time. B) Take oral preparations of prednisone before meals. C) Have periodic complete blood counts while on the medication. D) Never stop or change the amount of the medication without medical advice. 22. A pregnant client tells the nurse that she is worried about having urinary frequency. What will be the most appropriate nursing response? A) Try using Kegel (perineal) exercises and limiting fluids before bedtime. If you have frequency associated with fever, pain on voiding, or blood in the urine, call your doctor/nursemidwife. B) Placental progesterone causes irritability of the bladder sphincter. Your symptoms will go away after the baby comes. C) Pregnant women urinate frequently to get rid of fetal wastes. Limit fluids to 1L/daily. D) Frequency is due to bladder irritation from concentrate urine and is normal in pregnancy. Increase your daily fluid intake to 3L. 23. Which of the following will help the nurse determine that the expression of hostility is useful? A) Expression of anger dissipates the energy. B) Energy from anger is used to accomplish what needs to be done. C) Expression intimidates others. D) Degree of hostility is less than the provocation. 24. The nurse is providing an orientation regarding case management to the nursing students. Which characteristics should the nurse include in the discussion in understanding case management? A) Main objective is a written plan that combines discipline-specific processes used to measure outcomes of care. B) Main purpose is to identify expected client,

family and staff performance against the timeline for clients with the same diagnosis. C) Main focus is comprehensive coordination of client care, avoid unnecessary duplication of services, improve resource utilization and decrease cost. D) Primary goal is to understand why predicted outcomes have not been met and the correction of identified problems. 25. The physician orders a dose of IV phenytoin to a child client. In preparing in the administration of the drug, which nursing action is not correct? A) Infuse the phenytoin into a smaller vein to prevent purple glove syndrome. B) Check the phenytoin solution to be sure it is clear or light yellow in color, never cloudy. C) Plan to give phenytoin over 30-60 minutes, using an in-line filter. D) Flush the IV tubing with normal saline before starting phenytoin. 26. The pregnant woman visits the clinic for check up. Which assessment findings will help the nurse determine that the client is in 8-week gestation? A) Leopold maneuvers. B) Fundal height. C) Positive radioimmunoassay test (RIA test). D) Auscultation of fetal heart tones. 27. Which of the following nursing intervention is essential for the client who had pneumonectomy? A) Medicate for pain only when needed. B) Connect the chest tube to water-seal drainage. C) Notify the physician if the chest drainage exceeds 100mL/hr. D) Encourage deep breathing and coughing. 28. The nurse is providing a health teaching to a group of parents regarding Chlamydia trachomatis. The nurse is correct in the statement, Chlamydia trachomatis is not only an intracellular bacterium that causes neonatal conjunctivitis, but it also can cause: A) Discoloration of baby and adult teeth. B) Pneumonia in the newborn. C) Snuffles and rhagades in the newborn. D) Central hearing defects in infancy. 29. The nurse is assigned to care to a 17-yearold male client with a history of substance abuse. The client asks the nurse, Have you ever tried or used drugs? The most correct response of the nurse would be: A) Yes, once I tried grass. B) No, I dont think so.

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C) Why do you want to know that? D) How will my answer help you? 30. Which of the following describes a health care team with the principles of participative leadership? A) Each member of the team can independently make decisions regarding the clients care without necessarily consulting the other members. B) The physician makes most of the decisions regarding the clients care. C) The team uses the expertise of its members to influence the decisions regarding the clients care. D) Nurses decide nursing care; physicians decide medical and other treatment for the client. 31. A nurse is giving a health teaching to a woman who wants to breastfeed her newborn baby. Which hormone, normally secreted during the postpartum period, influences both the milk ejection reflex and uterine involution? A) Oxytocin. B) Estrogen. C) Progesterone. D) Relaxin. 32. One staff nurse is assigned to a group of 5 patients for the 12-hour shift. The nurse is responsible for the overall planning, giving and evaluating care during the entire shift. After the shift, same responsibility will be endorsed to the next nurse in charge. This describes nursing care delivered via the: A) Primary nursing method. B) Case method. C) Functional method. D) Team method. 33. The ambulance team calls the emergency department that they are going to bring a client who sustained burns in a house fire. While waiting for the ambulance, the nurse will anticipate emergency care to include assessment for: A) Gas exchange impairment. B) Hypoglycemia. C) Hyperthermia. D) Fluid volume excess. 34. Most couples are using natural family planning methods. Most accidental pregnancies in couples preferred to use this method have been related to unprotected intercourse before ovulation. Which of the following factor explains why pregnancy may be achieved by unprotected intercourse during the preovulatory period? A) Ovum viability. B) Tubal motility.

C) Spermatozoal viability. D) Secretory endometrium. 35. An older adult client wakes up at 2 oclock in the morning and comes to the nurses station saying, I am having difficulty in sleeping. What is the best nursing response to the client? A) Ill give you a sleeping pill to help you get more sleep now. B) Perhaps youd like to sit here at the nurses station for a while. C) Would you like me to show you where the bathroom is? D) What woke you up? 36. The nurse is taking care of a multipara who is at 42 weeks of gestation and in active labor, her membranes ruptured spontaneously 2 hours ago. While auscultating for the point of maximum intensity of fetal heart tones before applying an external fetal monitor, the nurse counts 100 beats per minute. The immediate nursing action is to: A) Start oxygen by mask to reduce fetal distress. B) Examine the woman for signs of a prolapsed cord. C) Turn the woman on her left side to increase placental perfusion. D) Take the womans radial pulse while still auscultating the FHR. 37. The nurse must instruct a client with glaucoma to avoid taking over-the-counter medications like: A) Antihistamines. B) NSAIDs. C) Antacids. D) Salicylates. 38. A male client is brought to the emergency department due to motor vehicle accident. While monitoring the client, the nurse suspects increasing intracranial pressure when: A) Client is oriented when aroused from sleep, and goes back to sleep immediately. B) Blood pressure is decreased from 160/90 to 110/70. C) Client refuses dinner because of anorexia. D) Pulse is increased from 88-96 with occasional skipped beat. 39. The nurse is conducting a lecture to a class of nursing students about advance directives to preoperative clients. Which of the following statement by the nurse js correct? A) The spouse, but not the rest of the family, may override the advance directive. B) An advance directive is required for a do not resuscitate order. C) A durable power of attorney, a form of advance directive, may only be held by a blood

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relative. D) The advance directive may be enforced even in the face of opposition by the spouse. 40. A client diagnosed with schizophrenia is shouting and banging on the door leading to the outside, saying, I need to go to an appointment. What is the appropriate nursing intervention? A) Tell the client that he cannot bang on the door. B) Ignore this behavior. C) Escort the client going back into the room. D) Ask the client to move away from the door. 41. Which of the following action is an accurate tracheal suctioning technique? A) 25 seconds of continuous suction during catheter insertion. B) 20 seconds of continuous suction during catheter insertion. C) 10 seconds of intermittent suction during catheter withdrawal. D) 15 seconds of intermittent suction during catheter withdrawal. 42. The clients jaw and cheekbone is sutured and wired. The nurse anticipates that the most important thing that must be ready at the bedside is: A) Suture set. B) Tracheostomy set. C) Suction equipment. D) Wire cutters. 43. A mother is in the third stage of labor. Which of the following signs will help the nurse determine the signs of placental separation? A) The uterus becomes globular. B) The umbilical cord is shortened. C) The fundus appears at the introitus. D) Mucoid discharge is increased. 44. After therapy with the thrombolytic alteplase (t-PA), what observation will the nurse report to the physician? A) 3+ peripheral pulses. B) Change in level of consciousness and headache. C) Occasional dysrhythmias. D) Heart rate of 100/bpm. 45. A client who undergone left nephrectomy has a large flank incision. Which of the following nursing action will facilitate deep breathing and coughing? A) Push fluid administration to loosen respiratory secretions. B) Have the client lie on the unaffected side.

C) Maintain the client in high Fowlers position. D) Coordinate breathing and coughing exercise with administration of analgesics. 46. The community nurse is teaching the group of mothers about the cervical mucus method of natural family planning. Which characteristics are typical of the cervical mucus during the fertile period of the menstrual cycle? A) Absence of ferning. B) Thin, clear, good spinnbarkeit. C) Thick, cloudy. D) Yellow and sticky. 47. A client with ruptured appendix had surgery an hour ago and is transferred to the nursing care unit. The nurse placed the client in a semiFowlers position primarily to: A) Facilitate movement and reduce complications from immobility. B) Fully aerate the lungs. C) Splint the wound. D) Promote drainage and prevent subdiaphragmatic abscesses. 48. Which of the following will best describe a management function? A) Writing a letter to the editor of a nursing journal. B) Negotiating labor contracts. C) Directing and evaluating nursing staff members. D) Explaining medication side effects to a client. 49. The parents of an infant client ask the nurse to teach them how to administer Cortisporin eye drops. The nurse is correct in advising the parents to place the drops: A) In the middle of the lower conjunctival sac of the infants eye. B) Directly onto the infants sclera. C) In the outer canthus of the infants eye. D) In the inner canthus of the infants eye. 50. The nurse is assessing on the client who is admitted due to vehicle accident. Which of the following findings will help the nurse that there is internal bleeding? A) Frank blood on the clothing. B) Thirst and restlessness. C) Abdominal pain. D) Confusion and altered of consciousness. 51. The nurse is completing an assessment to a newborn baby boy. The nurse observes that the skin of the newborn is dry and flaking and there are several areas of an apparent macular rash. The nurse charts this as:

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A) Icterus neonatorum B) Multiple hemangiomas C) Erythema toxicum D) Milia 52. The client is brought to the emergency department because of serious vehicle accident. After an hour, the client has been declared brain dead. The nurse who has been with the client must now talk to the family about organ donation. Which of the following consideration is necessary? A) Include as many family members as possible. B) Take the family to the chapel. C) Discuss life support systems. D) Clarify the familys understanding of brain death. 53. The nurse is teaching exercises that are good for pregnant women increasing tone and fitness and decreasing lower backache. Which of the following should the nurse exclude in the exercise program? A) Stand with legs apart and touch hands to floor three times per day. B) Ten minutes of walking per day with an emphasis on good posture. C) Ten minutes of swimming or leg kicking in pool per day. D) Pelvic rock exercise and squats three times a day. 54. A client with obsessive-compulsive behavior is admitted in the psychiatric unit. The nurse taking care of the client knows that the primary treatment goal is to: A) Provide distraction. B) Support but limit the behavior. C) Prohibit the behavior. D) Point out the behavior. 55. After ileostomy, the nurse expects that the drainage appliance will be applied to the stoma: A) When the client is able to begin self-care procedures. B) 24 hours later, when the swelling subsided. C) In the operating room after the ileostomy procedure. D) After the ileostomy begins to function. 56. A female client who has a 28-day menstrual cycle asks the community health nurse when she get pregnant during her cycle. What will be the best nursing response? A) It is impossible to determine the fertile period reliably. So it is best to assume that a woman is always fertile. B) In a 28-day cycle, ovulation occurs at or about day 14. The egg lives for about 24 hours and the sperm live for about 72 hours. The fertile period would be approximately between day 11 and day

15. C) In a 28- day cycle, ovulation occurs at or about day 14. The egg lives for about 72 hours and the sperm live for about 24 hours. The fertile period would be approximately between day 13 and 17. D) In a 28-day cycle, ovulation occurs 8 days before the next period or at about day 20. The fertile period is between day 20 and the beginning of the next period. 57. Which of the following statement describes the role of a nurse as a client advocate? A) A nurse may override clients wishes for their own good. B) A nurse has the moral obligation to prevent harm and do well for clients. C) A nurse helps clients gain greater independence and self-determination. D) A nurse measures the risk and benefits of various health situations while factoring in cost. 58. A community health nurse is providing a health teaching to a woman infected with herpes simplex 2. Which of the following health teaching must the nurse include to reduce the chances of transmission of herpes simplex 2? A) Abstain from intercourse until lesions heal. B) Therapy is curative. C) Penicillin is the drug of choice for treatment. D) The organism is associated with later development of hydatidiform mole. 59. The nurse in the psychiatric ward informed the male client that he will be attending the 9:00 AM group therapy sessions. The client tells the nurse that he must wash his hands from 9:00 to 9:30 AM each day and therefore he cannot attend. Which concept does the nursing staff need to keep in mind in planning nursing intervention for this client? A) Depression underlines ritualistic behavior. B) Fear and tensions are often expressed in disguised form through symbolic processes. C) Ritualistic behavior makes others uncomfortable. D) Unmet needs are discharged through ritualistic behavior. 10. The nurse assesses the health condition of the female client. The client tells the nurse that she discovered a lump in the breast last year and hesitated to seek medical advice. The nurse understands that, women who tend to delay seeking medical advice after discovering the disease are displaying what common defense mechanism? A) Intellectualization. B) Suppression. C) Repression. D) Denial.

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61. Which of the following situations cannot be delegated by the registered nurse to the nursing assistant? A) A postoperative client who is stable needs to ambulate. B) Client in soft restraint who is very agitated and crying. C) A confused elderly woman who needs assistance with eating. D) Routine temperature check that must be done for a client at end of shift. 62. In the admission care unit, which of the following client would the nurse give immediate attention? A) A client who is 3 days postoperative with left calf pain. B) A client who is postoperative hip pinning who is complaining of pain. C) New admitted client with chest pain. D) A client with diabetes who has a glucoscan reading of 180. 63. A couple seeks medical advice in the community health care unit. A couple has been unable to conceive; the man is being evaluated for possible problems. The physician ordered semen analysis. Which of the following instructions is correct regarding collection of a sperm specimen? A) Collect a specimen at the clinic, place in iced container, and give to laboratory personnel immediately. B) Collect specimen after 48-72 hours of abstinence and bring to clinic within 2 hours. C) Collect specimen in the morning after 24 hours of abstinence and bring to clinic immediately. D) Collect specimen at night, refrigerate, and bring to clinic the next morning. 64. The physician ordered Betamethasone to a pregnant woman at 34 weeks of gestation with sign of preterm labor. The nurse expects that the drug will: A) Treat infection. B) Suppress labor contraction. C) Stimulate the production of surfactant. D) Reduce the risk of hypertension. 65. A tracheostomy cuff is to be deflated, which of the following nursing intervention should be implemented before starting the procedures? A) Suction the trachea and mouth. B) Have the obdurator available. C) Encourage deep breathing and coughing. D) Do a pulse oximetry reading. 66. A client is diagnosed with Tuberculosis and respiratory isolation is initiated. This means that:

A) Gloves are worn when handling the clients tissue, excretions, and linen. B) Both client and attending nurse must wear masks at all times. C) Nurse and visitors must wear masks until chemotherapy is begun. Client is instructed in cough and tissue techniques. D) Full isolation; that is, caps and gowns are required during the period of contagion. 67. A client with lung cancer is admitted in the nursing care unit. The husband wants to know the condition of his wife. How should the nurse respond to the husband? A) Find out what information he already has. B) Suggest that he discuss it with his wife. C) Refer him to the doctor. D) Refer him to the nurse in charge. 68. A hospitalized client cannot find his handkerchief and accuses other cient in the room and the nurse of stealing them. Which is the most therapeutic approach to this client? A) Divert the clients attention. B) Listen without reinforcing the clients belief. C) Inject humor to defuse the intensity. D) Logically point out that the client is jumping to conclusions. 69. After a cystectomy and formation of an ileal conduit, the nurse provides instruction regarding prevention of leakage of the pouch and backflow of the urine. The nurse is correct to include in the instruction to empty the urine pouch: A) Every 3-4 hours. B) Every hour. C) Twice a day. D) Once before bedtime. 70. Which telephone call from a students mother should the school nurse take care of at once? A) A telephone call notifying the school nurse that the child pediatrician has informed the mother that the child will need cardiac repair surgery within the next few weeks. B) A telephone call notifying the school nurse that the childs pediatrician has informed the mother that the child has head lice. C) A telephone call notifying the school nurse that a child has a temperature of 102F and a rash covering the trunk and upper extremities of the body. D) A telephone call notifying the school nurse that a child underwent an emergency appendectomy during the previous night. 71. Which of the following signs and symptoms that require immediate attention and may indicate most serious complications during pregnancy?

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A) Severe abdominal pain or fluid discharge from the vagina. B) Excessive saliva, bumps around the areolae, and increased vaginal mucus. C) Fatigue, nausea, and urinary frequency at any time during pregnancy. D) Ankle edema, enlarging varicosities, and heartburn. 72. The nurse is assessing the newborn boy. Apgar scores are 7 and 9. The newborn becomes slightly cyanotic. What is the initial nursing action? A) Elevate his head to promote gravity drainage of secretions. B) Wrap him in another blanket, to reduce heat loss. C) Stimulate him to cry,, to increase oxygenation. D) Aspirate his mouth and nose with bulb syringe. 73. The nurse is formulating a plan of care to a client with a somatoform disorder. The nurse needs to have knowledge of which psychodynamic principle? A) The symptoms of a somatoform disorder are an attempt to adjust to painful life situations or to cope with conflicting sexual, aggressive, or dependent feelings. B) The major fundamental mechanism is regression. C) The clients symptoms are imaginary and the suffering is faked. D) An extensive, prolonged study of the symptoms will be reassuring to the client, who seeks sympathy, attention and love. 74. An infant is brought to the health care clinic for three immunizations at the same time. The nurse knows that hepatitis B, DPT, and Haemophilus influenzae type B immunizations should: A) Be drawn in the same syringe and given in one injection. B) Be mixed and inject in the same sites. C) Not be mixed and the nurse must give three injections in three sites. D) Be mixed and the nurse must give the injection in three sites. 75. A female client with cancer has radium implants. The nurse wants to maintain the implants in the correct position. The nurse should position the client: A) Flat in bed. B) On the side only. C) With the foot of the bed elevated. D) With the head elevated 45-degrees (semiFowlers). 76. The nurse wants to know if the mother of a toddler understands the instructions regarding the administration of syrup of ipecac. Which of

the following statement will help the nurse to know that the mother needs additional teaching? A) Ill give the medicine if my child gets into some toilet bowl cleaner. B) Ill give the medicine if my child gets into some aspirin. C) Ill give the medicine if my child gets into some plant bulbs. D) Ill give the medicine if my child gets into some vitamin pills. 77. To assess if the cranial nerve VII of the client was damaged, which changes would not be expected? A) Drooling and drooping of the mouth. B) Inability to open eyelids on operative side. C) Sagging of the face on the operative side. D) Inability to close eyelid on operative side. 78. The community health nurse makes a home visit to a family. During the visit, the nurse observes that the mother is beating her child. What is the priority nursing intervention in this situation? A) Assess the childs injuries. B) Report the incident to protective agencies. C) Refer the family to appropriate support group. D) Assist the family to identify stressors and use of other coping mechanisms to prevent further incidents. 79. The nurse in the neonatal care unit is supervising the actions of a certified nursing assistant in giving care to the newborns. The nursing assistant mistakenly gives a formula feeding to a newborn that is on water feeding only. The nurse is responsible for the mistake of the nursing assistant: A) Always, as a representative of the institution. B) Always, because nurses who supervise lesstrained individuals are responsible for their mistakes. C) If the nurse failed to determine whether the nursing assistant was competent to take care of the client. D) Only if the nurse agreed that the newborn could be fed formula. 80. The nurse is assigned to care for a client with urinary calculi. Fluid intake of 2L/day is encouraged to the client. the primary reason for this is to: A) Reduce the size of existing stones. B) Prevent crystalline irritation to the ureter. C) Reduce the size of existing stones D) Increase the hydrostatic pressure in the urinary tract. 81. The nurse is counseling a couple in their mid 30s who have been unable to conceive for about 6 months. They are concerned that one or both

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of them may be infertile. What is the best advice the nurse could give to the couple? A) it is no unusual to take 6-12 months to get pregnant, especially when the partners are in their mid-30s. Eat well, exercise, and avoid stress. B) Start planning adoption. Many couples get pregnant when they are trying to adopt. C) Consult a fertility specialist and start testing before you get any older. D) Have sex as often as you can, especially around the time of ovulation, to increase your chances of pregnancy. 82. The nurse is caring for a cient who Is a retired nurse. A 24-hour urine collection for Creatinine clearance is to be done. The client tells the nurse, I cant remember what this test is for. The best response by the nurse is: A) It provides a way to see if you are passing any protein in your urine. B) It tells how well the kidneys filter wastes from the blood. C) It tells if your renal insufficiency has affected your heart. D) The test measures the number of particles the kidney filters. 83. The nurse observes the female client in the psychiatric ward that she is having a hard time sleeping at night. The nurse asks the client about it and the client says, I cant sleep at night because of fear of dying. What is the best initial nursing response? A) It must be frightening for you to feel that way. Tell me more about it. B) Dont worry, you wont die. You are just here for some test. C) Why are you afraid of dying? D) Try to sleep. You need the rest before tomorrows test. 84. In the hospital lobby, the registered nurse overhears a two staff members discussing about the health condition of her client. What would be the appropriate action for the registered nurse to take? A) Join in the conversation, giving her input about the case. B) Ignore them, because they have the right to discuss anything they want to. C) Tell them it is not appropriate to discuss such things. D) Report this incident to the nursing supervisor. 85. The client has had a right-sided cerebrovascular accident. In transferring the client from the wheelchair to bed, in what position should a client be placed to facilitate safe transfer? A) Weakened (L) side of the cient next to bed. B) Weakened (R) side of the client next to bed.

C) Weakened (L) side of the client away from bed. D) Weakened (R) side of the cient away from bed. 86. The child client has undergone hip surgery and is in a spica cast. Which of the following toy should be avoided to be in the childs bed? A) A toy gun. B) A stuffed animal. C) A ball. D) Legos. 87. The LPN/LVN asks the registered nurse why oxytocin (Pitocin), 10 units (IV or IM) must be given to a client after birth fo the fetus. The nurse is correct to explain that oxytocin: A) Minimizes discomfort from afterpains. B) Suppresses lactation. C) Promotes lactation. D) Maintains uterine tone. 88. The nurse in the nursing care unit is aware that one of the medical staff displays unlikely behaviors like confusion, agitation, lethargy and unkempt appearance. This behavior has been reported to the nurse manager several times, but no changes observed. The nurse should: A) Continue to report observations of unusual behavior until the problem is resolved. B) Consider that the obligation to protect the patient from harm has been met by the prior reports and do nothing further. C) Discuss the situation with friends who are also nurses to get ideas . D) Approach the partner of this medical staff member with these concerns. 89. The physician ordered tetracycline PO qid to a child client who weights 20kg. The recommended PO tetracycline dose is 25-50 mg/kg/day. What is the maximum single dose that can be safely administered to this child? A) 1 g B) 500 mg C) 250 mg D) 125 mg 90. The nurse is completing an obstetric history of a woman in labor. Which event in the obstetric history will help the nurse suspects dysfunctional labor in the current pregnancy? A) Total time of ruptured membranes was 24 hours with the second birth. B) First labor lasting 24 hours. C) Uterine fibroid noted at time of cesarean delivery. D) Second birth by cesarean for face presentation.

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91. The nurse is planning to talk to the client with an antisocial personality disorder. What would be the most therapeutic approach? A) Provide external controls. B) Reinforce the clients self-concept. C) Give the client opportunities to test reality. D) Gratify the clients inner needs. 92. The nurse is teaching a group of women about fertility awareness, the nurse should emphasize that basal body temperature: A) Can be done with a mercury thermometer but no a digital one. B) The average temperature taken each morning. C) Should be recorded each morning before any activity. D) Has a lower degree of accuracy in predicting ovulation than the cervical mucus test. 93. The nursing applicant has given the chance to ask questions during a job interview at a local hospital. What should be the most important question to ask that can increase chances of securing a job offer? A) Begin with questions about client care assignments, advancement opportunities, and continuing education. B) Decline to ask questions, because that is the responsibility of the interviewer. C) Ask as many questions about the facility as possible. D) Clarify information regarding salary, benefits, and working hours first, because this will help in deciding whether or not to take the job. 94. The nurse advised the pregnant woman that smoking and alcohol should be avoided during pregnancy. The nurse takes into account that the developing fetus is most vulnerable to environment teratogens that cause malformation during: A) The entire pregnancy. B) The third trimester. C) The first trimester. D) The second trimester. 95. A male client tells the nurse that there is a big bug in his bed. The most therapeutic nursing response would be: A) Silence. B) Wheres the bug? Ill kill it for you. C) I dont see a bug in your bed, but you seem afraid. D) You must be seeing things. 96. A pregnant client in late pregnancy is complaining of groin pain that seems worse on the right side. Which of the following is the most likely cause of it?

A) Beginning of labor. B) Bladder infection. C) Constipation. D) Tension on the round ligament. 97. The nurse is conducting a lecture to a group of volunteer nurses. The nurse is correct in imparting the idea that the Good Samaritan law protects the nurse from a suit for malpractice when: A) The nurse stops to render emergency aid and leaves before the ambulance arrives. B) The nurse acts in an emergency at his or her place of employment. C) The nurse refuses to stop for an emergency outside of the scope of employment. D) The nurse is grossly negligent at the scene of an emergency. 98. A woman is hospitalized with mild preeclampsia. The nurse is formulating a plan of care for this client, which nursing care is least likely to be done? A) Deep-tendon reflexes once per shift. B) Vital signs and FHR and rhythm q4h while awake. C) Absolute bed rest. D) Daily weight. 99. While feeding a newborn with an unrepaired cardiac defect, the nurse keeps on assessing the condition of the client. The nurse notes that the newborns respiration is 72 breaths per minute. What would be the initial nursing action? A) Burp the newborn. B) Stop the feeding. C) Continue the feeding. D) Notify the physician. 100. A client who undergone appendectomy 3 days ago is scheduled for discharge today. The nurse notes that the client is restless, picking at bedclothes and saying, I am late on my appointment, and calling the nurse by the wrong name. The nurse suspects: A) Panic reaction. B) Medication overdose. C) Toxic reaction to an antibiotic. D) Delirium tremens. Answer and Rationale :Pre-board Exam for November 2009 NLE 1. A. The oxytocic effect of Pitocin increases the intensity and durations of contractions; prolonged contractions will jeopardize the safetyof the fetus and necessitate discontinuing the drug. 2. B. It is of paramount importance to prevent the client from hurting himself or herself or others.

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3. B. After tonsillectomy, clear, cool liquids should be given. Citrus, carbonated, and hot or cold liquids should be avoided because they may irritate the throat. Red liquids should be avoided because they give the appearance of blood if the child vomits. Milk and milk products including pudding are avoided because they coat the throat, cause the child to clear the throat, and increase the risk of bleeding. 4. A. Phenylephrine, with frequent and continued use, can cause rebound congestion of mucous membranes. 5. B. The N 95 respirator is a high-particulate filtration mask that meets the CDC performance criteria for a tuberculosis respirator. 6. C. The most frequent cause of noncompliance to the treatment of chronic, or open-angle glaucoma is the miotic effects of pilocarpine. Pupillary constriction impedes normal accommodation, making night driving difficult and hazardous, reducing the clients ability to read for extended periods and making participation in games with fast-moving objects impossible. 7. B. This stops the sucking of air through the tube and prevents the entry of contaminants. In addition, clamping near the chest wall provides for some stability and may prevent the clamp from pulling on the chest tube. 8. D. Because umbilical cords insertion site is born before the fetal head, the cord may be compressed by the after-coming head in a breech birth. 9. B. It is important to externalize the anger away from self. 10. D. Development normally proceeds cephalocaudally; so the first major developmental milestone that the infant achieves is the ability to hold the head up within the first 8-12 weeks of life. In hypothyroidism, the infants muscle tone would be poor and the infant would not be able to achieve this milestone. 11. D. Get a senior nurse who know s the policies, the client, and the doctor. Generally speaking, a nurse should not accept telephone orders. However, if it is necessary to take one, follow the hospitals policy regarding telephone orders. Failure to followhospital policy could be considered negligence. In this case, the nurse was new and did not know the hospitals policy concerning telephone orders. The nurse was also unfamiliar with the doctor and the client. Therefore the nurse should not take the order unless a) no one else is available and b) it is an emergency situation. 12. C. The nurse is obligated to inform the nurse manager about changes in the condition of the client, which may change the decision made by the nurse manager. 13. A. Perinatal risk factors for the development

of Down syndrome include advanced maternal age, especially with the first pregnancy. 14. B. Assignments should be based on scope of practice and expertise. 15. B. The child who is concurrently taking digoxin and diuretics is at increased risk for digoxin toxicity due to the loss of potassium. The child and parents should be taught what foods are high in potassium, and the child should be encouraged to eat a high-potassium diet. In addition, the childs serum potassium level should be carefully monitored. 16. A. The responsible for an accurate informed consent is the physician. An exception to this answer would be a life-threatening emergency, but there are no data to support another response. 17. D. Asking the client to cough and take a deep breath will help determine if the chest tube is kinked or if the lungs has reexpanded. 18. B. Every event that exposes a client to harm should be recorded in an incident report, as well as reported to the appropriate supervisors in order to resolve the current problems and permit the institution to prevent the problem from happening again. 19. D. One of the earliest signs of digoxin toxicity is Bradycardia. For a toddler, any heart rate that falls below the norm of about 100-120 bpm would indicate Bradycardia and would necessitate holding the medication and notifying the physician. 20. B. This option is least threatening. 21. D. In preparing the client for discharge that is receiving prednisone, the nurse should caution the client to (a) take oral preparations after meals; (b) remember that routine checks of vital signs, weight, and lab studies are critical; (c) NEVER STOP OR CHANGE THE AMOUNT OF MEDICATION WITHOUT MEDICAL ADVICE; (d) store the medication in a light-resistant container. 22. A. Progesterone also reduces smooth muscle motility in the urinary tract and predisposes the pregnant woman to urinary tract infections. Women should contact their doctors if they exhibit signs of infection. Kegel exercise will help strengthen the perineal muscles; limiting fluids at bedtime reduces the possibility of being awakened by the necessity of voiding. 23. B. This is the proper use of anger. 24. C. There are several models of case management, but the commonality is comprehensive coordination of care to better predict needs of high-risk clients, decrease exacerbations and continually monitor progress overtime. 25. A. Phenytoin should be infused or injected into larger veins to avoid the discoloration know

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as purple glove syndrome; infusing into a smaller vein is not appropriate. 26. C. Serum radioimmunoassay (RIA) is accurate within 7days of conception. This test is specific for HCG, and accuracy is not compromised by confusion with LH. 27. D. Surgery and anesthesia can increase mucus production. Deep breathing and coughing are essential to prevent atelectasis and pneumonia in the clients only remaining lung. 28. B. Newborns can get pneumonia (tachypnea, mild hypoxia, cough, eosinophilia) and conjunctivitis from Chlamydia. 29. D. The client may perceive this as avoidance, but it is more important to redirect back to the client, especially in light of the manipulative behavior of drug abusers and adolescents. 30. C. It describes a democratic process in which all members have input in the clients care. 31. A. Contraction of the milk ducts and let-down reflex occur under the stimulation of oxytocin released by the posterior pituitary gland. 32. B. In case management, the nurse assumes total responsibility for meeting the needs of the client during the entire time on duty. 33. A. Smoke inhalation affects gas exchange. 34. C. Sperm deposited during intercourse may remain viable for about 3 days. If ovulation occurs during this period, conception may result. 35. B. This option shows acceptance (key concept) of this age-typical sleep pattern (that of waking in the early morning). 36. D. Taking the mothers pulse while listening to the FHR will differentiate between the maternal and fetal heart rates and rule out fetal Bradycardia. 37. A. Antihistamines cause pupil dilation and should be avoided with glaucoma. 38. A. This suggests that the level of consciousness is decreasing. 39. D. An advance directive is a form of informed consent, and only a competent adult or the holder of a durable power of attorney has the right to consent or refuse treatment. If the spouse does not hold the power of attorney, the decisions of the holder, even if opposed by the spouse, are enforced. 40. C. Gentle but firm guidance and nonverbal direction is needed to intervene when a client with schizophrenic symptoms is being disruptive. 41. C. Suctioning is only done for 10 seconds, intermittently, as the catheter is being withdrawn.

42. D. The priority for this client is being able to establish an airway. 43. A. Signs of placental separation include a change in the shape of the uterus from ovoid to globular. 44. B. This could indicate intracranial bleeding. Alteplase is a thrombolytic enzyme that lyses thrombi and emboli. Bleeding is an adverse effect. Monitor clotting times and signs of any gastrointestinal or internal bleeding. 45. D. Because flank incision in nephrectomy is directly below the diaphragm, deep breathing is painful. Additionally, there is a greater incisional pull each time the person moves than there is with abdominal surgery. Incisional pain following nephrectomy generally requires analgesics administration every 3-4 hours for 24-48 hours after surgery. Therefore, turning, coughing and deep-breathing exercises should be planned to maximize the analgesic effects. 46. B. Under high estrogen levels, during the period surrounding ovulation, the cervical mucus becomes thin, clear, and elastic (spinnbarkeit), facilitating sperm passage. 47. D. After surgery for a ruptured appendix, the client should be placed in a semi-Fowlers position to promote drainage and to prevent possible complications. 48. C. Directing and evaluation of staff is a major responsibility of a nursing manager. 49. A. The recommended procedure for administering eyedrops to any client calls for the drops to be placed in the middle of the lower conjunctival sac. 50. B. Thirst and restlessness indicate hypovolemia and hypoxemia. Internal bleeding is difficult to recognized and evaluate because it is not apparent. 51. C. Erythema toxicum is the normal, nonpathological macular newborn rash. 52. D. The family needs to understand what brain death is before talking about organ donation. They need time to accept the death of their family member. An environment conducive to discussing an emotional issue is needed. 53. A. Bending from the waist in pregnancy tends to make backache worse. 54. B. Support and limit setting decrease anxiety and provide external control. 55. C. The stoma drainage bag is applied in the operating room. Drainage from the ileostomy contains secretions that are rich in digestive enzymes and highly irritating to the skin. Protection of the skin from the effects of these enzymes is begun at once. Skin exposed to these enzymes even for a short time becomes reddened, painful and excoriated.

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56. B. It is the most accurate statement of physiological facts for a 28-day menstrual cycle: ovulation at day 14, egg life span 24 hours, sperm life span of 72 hours. Fertilization could occur from sperm deposited before ovulation. 57. C. An advocate role encourage freedom of choice, includes speaking out for the client, and supports the clients best interests. 58. A. Abstinence will eliminate any unnecessary pain during intercourse and will reduce the possibility of transmitting infection to ones sexual partner. 59. B. Anxiety is generated by group therapy at 9:00 AM. The ritualistic behavioral defense of hand washing decreases anxiety by avoiding group therapy. 60. D. Denial is a very strong defense mechanism used to allay the emotional effects of discovering a potential threat. Although denial has been found to be an effective mechanism for survival in some instances, such as during natural disasters, it may in greater pathology in a woman with potential breast carcinoma. 61. B. The registered nurse cannot delegate the responsibility for assessment and evaluation of clients. The status of the client in restraint requires further assessment to determine if there are additional causes for the behavior. 62. C. The client with chest pain may be having a myocardial infarction, and immediate assessment and intervention is a priority. 63. B. Is correct because semen analysis requires that a freshly masturbated specimen be obtained after a rest (abstinence) period of 48-72 hours. 64. C. Betamethasone, a form of cortisone, acts on the fetal lungs to produce surfactant. 65. A. Secretions may have pooled above the tracheostomy cuff. If these are not suctioned before deflation, the secretions may be aspirated. 66. C. Proper handling of sputum is essential to allay droplet transference of bacilli in the air. Clients need to be taught to cover their nose and mouth with tissues when sneezing or coughing. Chemotherapy generally renders the client noninfectious within days to a few weeks, usually before cultures for tubercle bacilli are negative. Until chemical isolation is established, many institutions require the client to wear a mask when visitors are in the room or when the nurse is in attendance. Client should be in a wellventilated room, without air recirculation, to prevent air contamination. 67. A. It is best to establish baseline information first. 68. B. Listening is probably the most effective response of the four choices. 69. A. Urine flow is continuous. The pouch has an

outlet valve for easy drainage every 3-4 hours. (the pouch should be changed every 3-5 days, or sooner if the adhesive is loose). 70. C. A high fever accompanied by a body rash could indicate that the child has a communicable disease and would have exposed other students to the infection. The school nurse would want to investigate this telephone call immediately so that plans could be instituted to control the spread of such infection. 71. A. Severe abdominal pain may indicate complications of pregnancy such as abortion, ectopic pregnancy, or abruption placenta; fluid discharge from the vagina may indicate premature rupture of the membrane. 72. D. Gentle aspiration of mucus helps maintain a patent airway, required for effective gas exchange. 73. A. Somatoform disorders provide a way of coping with conflicts. 74. C. Immunization should never be mixed together in a syringe, thus necessitating three separate injections in three sites. Note: some manufacturers make a premixed combination of immunization that is safe and effective. 75. A. Clients with radioactive implants should be positioned flat in bed to prevent dislodgement of the vaginal packing. The client may roll to the side for meals but the upper body should not be raised more than 20 degrees. 76. A. Syrup of ipecac is not administered when the ingested substances is corrosive in nature. Toilet bowl cleaners, as a collective whole, are highly corrosive substances. If the ingested substance burned the esophagus going down, it will burn the esophagus coming back up when the child begins to vomit after administration of syrup of ipecac. 77. B. Inability to open eyelids on operative side is seen with cranial nerve III damage. 78. A. Assessment of physical injuries (like bruises, lacerations, bleeding and fractures) is the first priority. 79. C. The nurse who is supervising others has a legal obligation to determine that they are competent to perform the assignment, as well as legal obligation to provide adequate supervision. 80. D. Increasing hydrostatic pressure in the urinary tract will facilitate passage of the calculi. 81. A. Infertility is not diagnosed until atleast 12months of unprotected intercourse has failed to produce a pregnancy. Older couples will experience a longer time to get pregnant. 82. B. Determining how well the kidneys filter wastes states the purpose of a Creatinine clearance test. 83. A. Acknowledging a feeling tone is the most

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therapeutic response and provides a broad opening for the client to elaborate feelings. 84. C. The behavior should be stopped. The first is to remind the staff that confidentiality maybe violated. 85. C. With a right-sided cerebrovascular accident the client would have left-sided hemiplegia or weakness. The clients good side should be closest to the bed to facilitate the transfer. 86. D. Legos are small plastic building blocks that could easily slip under the childs cast and lead to a break in skin integrity and even infection. Pencils, backscratchers, and marbles are some other narrow or small items that could easily slip under the childs cast and lead to a break in skin integrity and infection. 87. D. Oxytocin (Pitocin) is used to maintain uterine tone. 88. B. The submission of reports about incidents that expose clients to harm does not remove the obligation to report ongoing behavior as long as the risk to the client continues. 89. C. The recommended dosage of tetracycline is 25-50mg/kg/day. If the child weighs 20kg and the maximum dose is 50mg/kg, this would indicate a total daily dose of 1000mg of tetracycline. In this case, the child is being given this medication four times a day. Therefore the maximum single dose that can be given is 250mg (1000 mg of tetracycline divided by four doses.) 90. C. An abnormality in the uterine muscle could reduce the effectiveness of uterine contractions and lengthen the duration of subsequent labors. 91. A. Personality disorders stem from a weak superego, implying a lack of adequate controls. 92. C. The basal body temperature is the lowest body temperature of a healthy person that is taken immediately after waking and before getting out of bed. The BBT usually varies from 36.2 C to 36.3C during menses and for about 5-7 days afterward. About the time of ovulation, a slight drop in temperature may be seen, after ovulation in concert with the increasing progesterone levels of the early luteal phase, the BBT rises 0.2-0.4 C. This elevation remains until 2-3 days before menstruation, or if pregnancy has occurred. 93. A. This choice implies concern for client care and self-improvement. 94. C. The first trimester is the period of organogenesis, that is, cell differentiation into the various organs, tissues, and structures. 95. C. This response does not contradict the clients perception, is honest, and shows empathy. 96. D. Tension on round ligament occurs because

of the erect human posture and pressure exerted by the growing fetus. 97. D. The Good Samaritan Law does not impose a duty to stop at the scene of an emergency outside of the scope of employment, therefore nurses who do not stop are not liable for suit. 98. C. Although reducing environment stimuli and activity is necessary for a woman with mild preeclampsia, she will most probably have bathroom privileges. 99. B. A normal respiratory rate for a newborn is 30-40 breaths per minute. 100. D. The behavior described is likely to be symptoms of delirium tremens, or alcohol withdrawal (often unsuspected on a surgical unit.) 1. A 10 year old who has sustained a head injury is brought to the emergency department by his mother. A diagnosis of a mild concussion is made. At the time of discharge, nurse Ron should instruct the mother to: A. Withhold food and fluids for 24 hours. B. Allow him to play outdoors with his friends. C. Arrange for a follow up visit with the childs primary care provider in one week. C. Check for any change in responsiveness every two hours until the follow-up visit. 2. A male client has suffered a motor accident and is now suffering from hypovolemic shock. Nurse Helen should frequency assess the clients vital signs during the compensatory stage of shock, because: A. Arteriolar constriction occurs B. The cardiac workload decreases C. Decreased contractility of the heart occurs D. The parasympathetic nervous system is triggered 3. A paranoid male client with schizophrenia is losing weight, reluctant to eat, and voicing concerns about being poisoned. The best intervention by nurse Dina would be to: A. Allow the client to open canned or prepackaged food B. Restrict the client to his room until 2 lbs are gained C. Have a staff member personally taste all of the clients food D. Tell the client the food has been x-rayed by the staff and is safe 4. One day the mother of a young adult confides to nurse Frida that she is very troubled by he childs emotional illness. The nurses most therapeutic initial response would be: A. You may be able to lessen your feelings of guilt by seeking counseling

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B. It would be helpful if you become involved in volunteer work at this time C. I recognize its hard to deal with this, but try to remember that this too shall pass D. Joining a support group of parents who are coping with this problem can be quite helpful. 5. To check for wound hemorrhage after a client has had a surgery for the removal of a tumor in the neck, nurse grace should: A. Loosen an edge of the dressing and lift it to see the wound B. Observe the dressing at the back of the neck for the presence of blood C. Outline the blood as it appears on the dressing to observe any progression D. Press gently around the incision to express accumulated blood from the wound 6. A 16-year-old primigravida arrives at the labor and birthing unit in her 38th week of gestation and states that she is labor. To verify that the client is in true labor nurse Trina should: A. Obtain sides for a fern test B. Time any uterine contractions C. Prepare her for a pelvic examination D. Apply nitrazine paper to moist vaginal tissue 7. As part of the diagnostic workup for pulmonic stenosis, a child has cardiac catheterization. Nurse Julius is aware that children with pulmonic stenosis have increased pressure: A. In the pulmonary vein B. In the pulmonary artery C. On the left side of the heart D. On the right side of the heart 8. An obese client asks nurse Julius how to lose weight. Before answering, the nurse should remember that long-term weight loss occurs best when: A. Eating patterns are altered B. Fats are limited in the diet C. Carbohydrates are regulated D. Exercise is a major component 9. As a very anxious female client is talking to the nurse May, she starts crying. She appears to be upset that she cannot control her crying. The most appropriate response by the nurse would be: A. Is talking about your problem upsetting you? B. It is Ok to cry; Ill just stay with you for now C. You look upset; lets talk about why you are crying. D. Sometimes it helps to get it out of your system. 10. A patient has partial-thickness burns to both

legs and portions of his trunk. Which of the following I.V. fluids is given first? A. Albumin B. D5W C. Lactated Ringers solution D. 0.9% sodium chloride solution with 2 mEq of potassium per 100 ml 11. During the first 48 hours after a severe burn of 40% of the clients body surface, the nurses assessment should include observations for water intoxication. Associated adaptations include: A. Sooty-colored sputum B. Frothy pink-tinged sputum C. Twitching and disorientation D. Urine output below 30ml per hour 12. After a muscle biopsy, nurse Willy should teach the client to: A. Change the dressing as needed B. Resume the usual diet as soon as desired C. Bathe or shower according to preference D. Expect a rise in body temperature for 48 hours 13. Before a client whose left hand has been amputated can be fitted for a prosthesis, nurse Joy is aware that: A. Arm and shoulder muscles must be developed B. Shrinkage of the residual limb must be completed C. Dexterity in the other extremity must be achieved D. Full adjustment to the altered body image must have occurred 14. Nurse Cathy applies a fetal monitor to the abdomen of a client in active labor. When the client has contractions, the nurse notes a 15 beat per minute deceleration of the fetal heart rate below the baseline lasting 15 seconds. Nurse Cathy should: A. Change the maternal position B. Prepare for an immediate birth C. Call the physician immediately D. Obtain the clients blood pressure 15. A male client receiving prolonged steroid therapy complains of always being thirsty and urinating frequently. The best initial action by the nurse would be to: A. Perform a finger stick to test the clients blood glucose level B. Have the physician assess the client for an enlarged prostate C. Obtain a urine specimen from the client for screening purposes D. Assess the clients lower extremities for the presence of pitting edema

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16. Nurse Bea recognizes that a pacemaker is indicated when a client is experiencing: A. Angina B. Chest pain C. Heart block D. Tachycardia 17. When administering pancrelipase (Pancreases capsules) to child with cystic fibrosis, nurse Faith knows they should be given: A. With meals and snacks B. Every three hours while awake C. On awakening, following meals, and at bedtime C. After each bowel movement and after postural draianage 18. A preterm neonate is receiving oxygen by an overhead hood. During the time the infant is under the hood, it would be appropriate for nurse Gian to: A. Hydrate the infant q15 min B. Put a hat on the infants head C. Keep the oxygen concentration consistent D. Remove the infant q15 min for stimulation 19. A clients sputum smears for acid fast bacilli (AFB) are positive, and transmission-based airborne precautions are ordered. Nurse Kyle should instruct visitors to: A.Limit contact with non-exposed family members B. Avoid contact with any objects present in the clients room C. Wear an Ultra-Filter mask when they are in the clients room D. Put on a gown and gloves before going into the clients room 20. A client with a head injury has a fixed, dilated right pupil; responds only to painful stimuli; and exhibits decorticate posturing. Nurse Kate should recognize that these are signs of: A. Meningeal irritation B. Subdural hemorrhage C. Medullary compression D. Cerebral cortex compression 21. After a lateral crushing chest injury, obvious right-sided paradoxic motion of the clients chest demonstrates multiple rib fraactures, resulting in a flail chest. The complication the nurse should carefully observe for would be: A. Mediastinal shift B. Tracheal laceration C. Open pneumothorax D. Pericardial tamponade 22. When planning care for a client at 30-weeks

gestation, admitted to the hospital after vaginal bleeding secondary to placenta previa, the nurses primary objective would be: A. Provide a calm, quiet environment B. Prepare the client for an immediate cesarean birth C. Prevent situations that may stimulate the cervix or uterus D. Ensure that the client has regular cervical examinations assess for labor 23. When planning discharge teaching for a young female client who has had a pneumothorax, it is important that the nurse include the signs and symptoms of a pneumothorax and teach the client to seek medical assistance if she experiences: A. Substernal chest pain B. Episodes of palpitation C. Severe shortness of breath D. Dizziness when standing up 24. After a laryngectomy, the most important equipment to place at the clients bedside would be: A. Suction equipment B. Humidified oxygen C. A nonelectric call bell D. A cold-stream vaporizer 25. Nurse Oliver interviews a young female client with anorexia nervosa to obtain information for the nursing history. The clients history is likely to reveal a: A. Strong desire to improve her body image B. Close, supportive mother-daughter relationship C. Satisfaction with and desire to maintain her present weight D. Low level of achievement in school, with little concerns for grades 26. Nurse Bea should plan to assist a client with an obsessive-compulsive disorder to control the use of ritualistic behavior by: A. Providing repetitive activities that require little thought B. Attempting to reduce or limit situations that increase anxiety C. Getting the client involved with activities that will provide distraction D. Suggesting that the client perform menial tasks to expiate feelings of guilt 27. A 2 year old child undergoes a ventriculoperitoneal shunt revision. Before discharge, nurse John, knowing the expected developmental behaviors for this age group, should tell the parents to call the physician if the child: A. Tries to copy all the fathers mannerisms B. Talks incessantly regardless of the presence of

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others C. Becomes fussy when frustrated and displays a shortened attention span D. Frequently starts arguments with playmates by claiming all toys are mine 28. A urinary tract infection is a potential danger with an indwelling catheter. Nurse Gina can best plan to avoid this complication by: A. Assessing urine specific gravity B. Maintaining the ordered hydration C. Collecting a weekly urine specimen D. Emptying the drainage bag frequently 29. A client has sustained a fractured right femur in a fall on stairs. Nurse Troy with the emergency response team assess for signs of circulatory impairment by: A. Turning the client to side lying position B. Asking the client to cough and deep breathe C. Taking the clients pedal pulse in the affected limb D. Instructing the client to wiggle the toes of the right foot 30. To assess orientation to place in a client suspected of having dementia of the alzheimers type, nurse Chris should ask: A. Where are you? B. Who brought you here? C. Do you know where you are? D. How long have you been there? 31. Nurse Mary assesses a postpartum client who had an abruption placentae and suspects that disseminated intravascular coagulation (DIC) is occurring when assessments demonstrate: A. A boggy uterus B. Multiple vaginal clots C. Hypotension and tachycardia D. Bleeding from the venipuncture site 32. When a client on labor experiences the urge to push a 9cm dilation, the breathing pattern that nurse Rhea should instruct the client to use is the: A. Expulsion pattern B. Slow paced pattern C. Shallow chest pattern D. blowing pattern 33. Nurse Ronald should explain that the most beneficial between-meal snack for a client who is recovering from the full-thickness burns would be a: A. Cheeseburger and a malted B. Piece of blueberry pie and milk C. Bacon and tomato sandwich and tea D. Chicken salad sandwich and soft drink

34. Nurse Wilma recognizes that failure of a newborn to make the appropriate adaptation to extrauterine life would be indicated by: A. flexed extremities B. Cyanotic lips and face C. A heart rate of 130 beats per minute D. A respiratory rate of 40 breath per minute 35. The laboratory calls to state that a clients lithium level is 1.9 mEq/L after 10 days of lithium therapy. Nurse Reese should: A. Notify the physician of the findings because the level is dangerously high B. Monitor the client closely because the level of lithium in the blood is slightly elevated C. Continue to administer the medication as ordered because the level is within the therapeutic range D. Report the findings to the physician so the dosage can be increased because the level is below therapeutic range 36. A client has a regular 30-day menstrual cycles. When teaching about the rhythm method, Which the client and her husband have chosen to use for family planning, nurse Dianne should emphasize that the clients most fertile days are: A. Days 9 to 11 B. Days 12 to 14 C. Days 15 to 17 D. Days 18 to 20 37. Before an amniocentesis, nurse Alexandra should: A. Initiate the intravenous therapy as ordered by the physiscian B. Inform the client that the procedure could precipitate an infection C. Assure that informed consent has been obtained from the client D. Perform a vaginal examination on the client to assess cervical dilation 38. While a client is on intravenous magnesium sulfate therapy for preeclampsia, it is essential for nurse Amy to monitor the clients deep tendon reflexes to: A. Determine her level of consciousness B. Evaluate the mobility of the extremities C. Determine her response to painful stimuli D. Prevent development of respiratory distress 39. A preschooler is admitted to the hospital with a diagnosis of acute glomerulonephritis. The childs history reveals a 5-pound weight gain in one week and peritoneal edema. For the most accurate information on the status of the childs edema, nursing intervention should include:

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A. Obtaining the childs daily weight B. Doing a visual inspection of the child C. Measuring the childs intake and output D. Monitoring the childs electrolyte values 40. Nurse Mickey is administering dexamethasome (Decadron) for the early management of a clients cerebral edema. This treatment is effective because: A. Acts as hyperosmotic diuretic B. Increases tissue resistance to infection C. Reduces the inflammatory response of tissues D. Decreases the information of cerebrospinal fluid 41. During newborn nursing assessment, a positive Ortolanis sign would be indicated by: A. A unilateral droop of hip B. A broadening of the perineum C. An apparent shortening of one leg D. An audible click on hip manipulation 42. When caring for a dying client who is in the denial stage of grief, the best nursing approach would be to: A. Agree and encourage the clients denial B. Allow the denial but be available to discuss death C. Reassure the client that everything will be OK D. Leave the client alone to confront the feelings of impending loss 43. To decrease the symptoms of gastroesophageal reflux disease (GERD), the physician orders dietary and medication management. Nurse Helen should teach the client that the meal alteration that would be most appropriate would be: A. Ingest foods while they are hot B. Divide food into four to six meals a day C.Eat the last of three meals daily by 8pm D. Suck a peppermint candy after each meal 44. After a mastectomy or hysterectomy, clients may feel incomplete as women. The statement that should alert nurse Gina to this feeling would be: A. I cant wait to see all my friends again B. I feel washed out; there isnt much left C. I cant wait to get home to see my grandchild D. My husband plans for me to recuperate at our daughters home 45. A client with obstruction of the common bile duct may show a prolonged bleeding and clotting time because: A. Vitamin K is not absorbed B. The ionized calcium levels falls

C. The extrinsic factor is not absorbed D. Bilirubin accumulates in the plasma 46. Realizing that the hypokalemia is a side effect of steroid therapy, nurse Monette should monitor a client taking steroid medication for: A. Hyperactive reflexes B. An increased pulse rate C. Nausea, vomiting, and diarrhea D. Leg weakness with muscle cramps 47. When assessing a newborn suspected of having Down syndrome, nurse Rey would expect to observe: A. long thin fingers B. Large, protruding ears C. Hypertonic neck muscles D. Simian lines on the hands 48. A 10 year old girl is admitted to the pediatric unit for recurrent pain and swelling of her joints, particularly her knees and ankles. Her diagnosis is juvenile rheumatoid arthritis. Nurse Janah recognizes that besides joint inflammation, a unique manifestation of the rheumatoid process involves the: A. Ears B. Eyes C. Liver D. Brain 49. A disturbed client is scheduled to begin group therapy. The client refuses to attend. Nurse Lolit should: A. Accept the clients decision without discussion B. Have another client to ask the client to consider C. Tell the client that attendance at the meeting is required D. Insist that the client join the group to help the socialization process 50. Because a severely depressed client has not responded to any of the antidepressant medications, the psychiatrist decides to try electroconvulsive therapy (ECT). Before the treatment the nurse should: A. Have the client speak with other clients receiving ECT B. Give the client a detailed explanation of the entire procedure C. Limit the clients intake to a light breakfast on the days of the treatment D. Provide a simple explanation of the procedure and continue to reassure the client 51. Nurse Vicky is aware that teaching about colostomy care is understood when the client states, I will contact my physician and report ____":

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A. If I notice a loss of sensation to touch in the stoma tissue B. When mucus is passed from the stoma between irrigations C. The expulsion of flatus while the irrigating fluid is running out D. If I have difficulty in inserting the irrigating tube into the stoma 52. The clients history that alerts nurse Henry to assess closely for signs of postpartum infection would be: A. Three spontaneous abortions B. negative maternal blood type C. Blood loss of 850 ml after a vaginal birth D. Maternal temperature of 99.9 F 12 hours after delivery 53. A client is experiencing stomatitis as a result of chemotherapy. An appropriate nursing intervention related to this condition would be to: A. Provide frequent saline mouthwashes B. Use karaya powder to decrease irritation C. Increase fluid intake to compensate for the diarrhea D. Provide meticulous skin care of the abdomen with Betadine 54. During a group therapy session, one of the clients ask a male client with the diagnosis of antisocial personality disorder why he is in the hospital. Considering this clients type of personality disorder, the nurse might expect him to respond: A. I need a lot of help with my troubles B. Society makes people react in old ways C. I decided that its time I own up to my problems D. My life needs straightening out and this might help 55. A child visits the clinic for a 6-week checkup after a tonsillectomy and adenoidectomy. In addition to assessing hearing, the nurse should include an assessment of the childs: A. Taste and smell B. Taste and speech C. Swallowing and smell D. Swallowing and speech 56. A client is diagnosed with cancer of the jaw. A course of radiation therapy is to be followed by surgery. The client is concerned about the side effects related to the radiation treaments. Nurse Ria should explain that the major side effects that will experienced is: A. Fatigue B. Alopecia C. Vomiting D. Leucopenia

57. Nurse Katrina prepares an older-adult client for sleep, actions are taken to help reduce the likelihood of a fall during the night. Targeting the most frequent cause of falls, the nurse should: A. Offer the client assistance to the bathroom B. Move the bedside table closer to the clients bed C. Encourage the client to take an available sedative D. Assist the client to telephone the spouse to say goodnight 58. When evaluating a growth and development of a 6 month old infant, nurse Patty would expect the infant to be able to: A. Sit alone, display pincer grasp, wave bye bye B. Pull self to a standing position, release a toy by choice, play peek-a-boo C. Crawl, transfer toy from one hand to the other, display of fear of strangers D. Turn completely over, sit momentarily without support, reach to be picked up 59. A breastfeeding mother asks the nurse what she can do to ease the discomfort caused by a cracked nipple. Nurse Tina should instruct the client to: A. Manually express milk and feed it to the baby in a bottle B. Stop breastfeeding for two days to allow the nipple to heal C. Use a breast shield to keep the baby from direct contact with the nipple D. Feed the baby on the unaffected breast first until the affected breast heals 60. Nurse Sandy observes that there is blood coming from the clients ear after head injury. Nurse Sandy should: A. Turn the client to the unaffected side B. Cleanse the clients ear with sterile gauze C. Test the drainage from the clients ear with Dextrostix D. Place sterile cotton loosely in the external ear of the client 61. Nurse Gio plans a long term care for parents of children with sickle-cell anemia, which includes periodic group conferences. Some of the discussions should be directed towards: A. Finding special school facilities for the child B. Making plans for moving to a more therapeutic climate C. Choosing a means of birth control to avoid future pregnancies D. Airing their feelings regarding the transmission of the disease to the child 62. The central problem the nurse might face

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with a disturbed schizophrenic client is the clients: A. Suspicious feelings B. Continuous pacing C. Relationship with the family D. Concern about working with others 63. When planning care with a client during the postoperative recovery period following an abdominal hysterectomy and bilateral salpingooophorectomy, nurse Frida should include the explanation that: A. Surgical menopause will occur B. Urinary retention is a common problem C. Weight gain is expected, and dietary plan are needed D. Depression is normal and should be expected 64. An adolescent client with anorexia nervosa refuses to eat, stating, Ill get too fat. Nurse Andrea can best respond to this behavior initially by: A. Not talking about the fact that the client is not eating B. Stopping all of the clients priviledges until food is eaten C. Telling the client that tube feeding will eventually be necessary D. Pointing out to the client that death can occur with malnutrition. 65. A pain scale is used to assess the degree of pain. The client rates the pain as an 8 on a scale of 10 before medication and a 7 on a scale of 10 after being medicated. Nurse Glenda determines that the: A. Client has a low pain tolerance B. Medication is not adequately effective C. Medication has sufficiently decreased the pain level D. Client needs more education about the use of the pain scale 66. To enhance a neonates behavioral development, therapeutic nursing measures should include: A. Keeping the baby awake for longer periods of time before each feeding B. Assisting the parents to stimulate their baby through touch, sound, and sight. C. Encouraging parental contact for at least one 15-minute period every four hours. D. Touching and talking to the baby at least hourly, beginning within two to four hours after birth 67. Before formulating a plan of care for a 6 year old boy with attention deficit hyperactivity disorder (ADHD), nurse Kyla is aware that the initial aim of therapy is to help the client to:

A. Develop language skills B. Avoid his own regressive behavior C. Mainstream into a regular class in school D. Recognize himself as an independent person of worth 68. Nurse Wally knows that the most important aspect of the preoperative care for a child with Wilms tumor would be: A. Checking the size of the childs liver B. Monitoring the childs blood pressure C. Maintaining the child in a prone position D. Collecting the childs urine for culture and sensitivity 69. At 11:00 pm the count of hydrocodone (Vicodin) is incorrect. After several minutes of searching the medication cart and medication administration records, no explanation can be found. The primary nurse should notify the: A. Nursing unit manager B. Hospital administrator C. Quality control manager D. Physician ordering the medication 70. When caring for the a client with a pneumothorax, who has a chest tube in place, nurse Kate should plan to: A. Administer cough suppressants at appropriate intervals as ordered B. Empty and measure the drainage in the collection chamber each shift C. Apply clamps below the insertion site when ever getting the client out of bed D. Encourage coughing, deep breathing, and range of motion to the arm on the affected side 71. According to C.E.Winslow, which of the following is the goal of Public Health? A. For people to attain their birthrights of health and longevity B. For promotion of health and prevention of disease C. For people to have access to basic health services D. For people to be organized in their health efforts 72. What other statistic may be used to determine attainment of longevity? A. Age-specific mortality rate B. Proportionate mortality rate C. Swaroops index D. Case fatality rate 73. Which of the following is the most prominent feature of public health nursing? A. It involves providing home care to sick people who are not confined in the hospital

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B. Services are provided free of charge to people within the catchment area. C. The public health nurse functions as part of a team providing a public health nursing services. D. Public health nursing focuses on preventive, not curative, services. 74. Which of the following is the mission of the Department of Health? A. Health for all Filipinos B. Ensure the accessibility and quality of health care C. Improve the general health status of the population D. Health in the hands of the Filipino people by the year 2020 75. Nurse Pauline determines whether resources were maximized in implementing Ligtas Tigdas, she is evaluating: A. Effectiveness B. Efficiency C. Adequacy D. Appropriateness 76. Lissa is a B.S.N. graduate. She want to become a Public Health Nurse. Where will she apply? A. Department of Health B. Provincial Health Office C. Regional Health Office D. Rural Health Unit 77. As an epidemiologist, Nurse Celeste is responsible for reporting cases of notifiable diseases. What law mandates reporting of cases of notifiable diseases? A. Act 3573 B. R.A. 3753 C. R.A. 1054 D. R.A. 1082 78. Nurse Fay is aware that isolation of a child with measles belongs to what level of prevention? A. Primary B. Secondary C. Intermediate D. Tertiary 79. Nurse Gina is aware that the following is an advantage of a home visit? A. It allows the nurse to provide nursing care to a greater number of people. B. It provides an opportunity to do first hand appraisal of the home situation. C. It allows sharing of experiences among people with similar health problems.

D. It develops the familys initiative in providing for health needs of its members. 80. The PHN bag is an important tool in providing nursing care during a home visit. The most important principle of bag technique states that it: A. Should save time and effort. B. Should minimize if not totally prevent the spread of infection. C. Should not overshadow concern for the patient and his family. D. May be done in a variety of ways depending on the home situation, etc. 81. Nurse Willy reads about Path Goal theory. Which of the following behaviors is manifested by the leader who uses this theory? A. Recognizes staff for going beyond expectations by giving them citations B. Challenges the staff to take individual accountability for their own practice C. Admonishes staff for being laggards D. Reminds staff about the sanctions for non performance 82. Nurse Cathy learns that some leaders are transactional leaders. Which of the following does NOT characterize a transactional leader? A. Focuses on management tasks B. Is a caretaker C. Uses trade-offs to meet goals D. Inspires others with vision 83. Functional nursing has some advantages, which one is an EXCEPTION? A. Psychological and sociological needs are emphasized. B. Great control of work activities. C. Most economical way of delivering nursing services. D. Workers feel secure in dependent role 84. Which of the following is the best guarantee that the patients priority needs are met? A. Checking with the relative of the patient B. Preparing a nursing care plan in collaboration with the patient C. Consulting with the physician D. Coordinating with other members of the team 85. Nurse Tony stresses the need for all the employees to follow orders and instructions from him and not from anyone else. Which of the following principles does he refer to? A. Scalar chain B. Discipline C. Unity of command D. Order

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components of a client's general background drug history? 86. Nurse Joey discusses the goal of the department. Which of the following statements is a goal? A. Increase the patient satisfaction rate B. Eliminate the incidence of delayed administration of medications C. Establish rapport with patients D. Reduce response time to two minutes 87. Nurse Lou considers shifting to transformational leadership. Which of the following statements best describes this type of leadership? A. Uses visioning as the essence of leadership B. Serves the followers rather than being served C. Maintains full trust and confidence in the subordinates D. Possesses innate charisma that makes others feel good in his presence. 88. Nurse Mae tells one of the staff, I dont have time to discuss the matter with you now. See me in my office later when the latter asks if they can talk about an issue. Which of the following conflict resolution strategies did she use? A. Smoothing B. Compromise C. Avoidance D. Restriction 89. Nurse Bea plans of assigning competent people to fill the roles designed in the hierarchy. Which process refers to this? A. Staffing B. Scheduling C. Recruitment D. Induction 90. Nurse Linda tries to design an organizational structure that allows communication to flow in all directions and involve workers in decision making. Which form of organizational structure is this? A. Centralized B. Decentralized C. Matrix D. Informal 91. When documenting information in a client's medical record, the nurse should: A. erase any errors. B. use a #2 pencil. C. leave one line blank before each new entry. D. end each entry with the nurse's signature and title. 92. Which of the following factors are major A. Allergies and socioeconomic status B. Urine output and allergies C. Gastric reflex and age D. Bowel habits and allergies 93. Which procedure or practice requires surgical asepsis? A. Hand washing B. Nasogastric tube irrigation C. I.V. cannula insertion D. Colostomy irrigation 94. The nurse is performing wound care using surgical asepsis. Which of the following practices violates surgical asepsis? A. Holding sterile objects above the waist B. Pouring solution onto a sterile field cloth C. Considering a 1" (2.5-cm) edge around the sterile field contaminated D. Opening the outermost flap of a sterile package away from the body 95. On admission, a client has the following arterial blood gas (ABG) values: PaO2, 50 mm Hg; PaCO2, 70 mm Hg; pH, 7.20; HCO3, 28 mEq/L. Based on these values, the nurse should formulate which nursing diagnosis for this client? A. Risk for deficient fluid volume B. Deficient fluid volume C. Impaired gas exchange D. Metabolic acidosis 96. The use of larvivorous fish in malaria control is the basis for which strategy of malaria control? A. Stream seeding B. Stream clearing C. Destruction of breeding places D. Zooprophylaxis 97. In Integrated Management of Childhood Illness, severe conditions generally require urgent referral to a hospital. Which of the following severe conditions DOES NOT always require urgent referral to a hospital? A. Mastoiditis B. Severe dehydration C. Severe pneumonia D. Severe febrile disease 98. A mother brought her daughter, 4 years old, to the RHU because of cough and colds. Following the IMCI assessment guide, which of the following is a danger sign that indicates the need for urgent referral to a hospital?

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A. Inability to drink B. High grade fever C. Signs of severe dehydration D. Cough for more than 30 days 99. Food fortification is one of the strategies to prevent micronutrient deficiency conditions. R.A. 8976 mandates fortification of certain food items. Which of the following is among these food items? A. Sugar B. Bread C. Margarine D. Filled milk 100. The major sign of iron deficiency anemia is pallor. What part is best examined for pallor? A. Palms B. Nailbeds C. Around the lips D. Lower conjunctival sac 1. C. Check for any change in responsiveness every two hours until the follow-up visit Signs of an epidural hematoma in children usually do not appear for 24 hours or more hours; a follow-up visit usually is arranged for one to two days after the injury. 2. A. Arteriolar constriction occurs The early compensation of shock is cardiovascular and is seen in changes in pulse, BP, and pulse pressure; blood is shunted to vital centers, particularly heart and brain. 3. A. Allow the client to open canned or prepackaged food The clients comfort, safety, and nutritional status are the priorities; the client may feel comfortable to eat if the food has been sealed before reaching the mental health facility. 4. D. Joining a support group of parents who are coping with this problem can be quite helpful. Taking with others in similar circumstances provides support and allows for sharing of experiences. 5. B. Observe the dressing at the back of the neck for the presence of blood Drainage flows by gravity. 6. C. Prepare her for a pelvic examination Pelvic examination would reveal dilation and effacement 7. D. On the right side of the heart Pulmonic stenosis increases resistance to blood flow, causing right ventricular hyperthropy; with right ventricular failure there is an increase in pressure on the right side of the heart. 8. A. Eating patterns are altered

A new dietary regimen, with a balance of foods from the food pyramid, must be established and continued forweight reduction to occur and be maintained. 9. B. It is Ok to cry; Ill just stay with you for now This portrays a nonjudgmental attitude that recognizes the clients needs. 10. C. Lactated Ringers solution Lactated Ringers solution replaces lost sodium and corrects metabolic acidosis, both of which commonly occur following a burn. Albumin is used as adjunct therapy, not primary fluid replacement. Dextrose isnt given to burn patients during the first 24 hours because it can cause pseudodiabetes. The patient is hyperkalemic from the potassium shift from the intracellular space to the plasma, so potassium would be detrimental. 11. C. Twitching and disorientation Excess extracellular fluid moves into cells (water intoxication); intracellular fluid excess in sensitive brain cells causes altered mental status; other signs include anorexia nervosa, nausea, vomiting, twitching, sleepiness, and convulsions. 12. B. Resume the usual diet as soon as desired As long as the client has no nausea or vomiting, there are no dietary restriction. 13. B. Shrinkage of the residual limb must be completed Shrinkage of the residual limb, resulting from reduction of subcutaneous fat and interstitial fluid, must occur for an adequate fit between the limb and the prosthesis. 14. A. Change the maternal position Stimulation of the sympathetic nervous system is an initial response to mild hypoxia that accompanies partial cord compression (umbilical vein) during contractions; changing the maternal position can alleviate the compression. 15. A. Perform a finger stick to test the clients blood glucose level The client has signs of diabetes, which may result from steroid therapy, testing the blood glucose level is a method of screening for diabetes, thus gathering more data. 16. C. Heart block This is the primary indication for a pacemaker because there is an interfere with the electrical conduction system of the heart. 17. A. With meals and snacks Pancreases capsules must be taken with food and snacks because it acts on the nutrients and readies them for absorption. 18. B. Put a hat on the infants head Oxygen has cooling effect, and the baby should be kept warm so that metabolic activity and oxygen demands are not increased.

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19. C. Wear an Ultra-Filter mask when they are in the clients room Tubercle bacilli are transmitted through air currents; therefore personal protective equipment such as an Ultra-Filter mask is necessary. 20. D. Cerebral cortex compression Cerebral compression affects pyramidal tracts, resulting in decorticate rigidity and cranial nerve injury, which cause pupil dilation. 21. A.Mediastinal shift Mediastinal structures move toward the uninjured lung, reducing oxygenation and venous return. 22. C. Prevent situations that may stimulate the cervix or uterus Stimulation of the cervix or uterus may cause bleeding or hemorrhage and should be avoided. 23. C. Severe shortness of breath This could indicate a recurrence of the pneumothorax as one side of the lung is inadequate to meet the oxygen demands of the body. 24. A. Suction equipment Respiratory complications can occur because of edema of the glottis or injury to the recurrent laryngeal nerve. 25. A. Strong desire to improve her body image Clients with anorexia nervosa have a disturbed self image and always see themselves as fat and needing further reducing. 26. B. Attempting to reduce or limit situations that increase anxiety Persons with high anxiety levels develop various behaviors to relieve their anxiety; by reducing anxiety, the need for these obsessive-compulsive action is reduced. 27. C. Becomes fussy when frustrated and displays a shortened attention span Shortened attention span and fussy behavior may indicate a change in intracranial pressure and/or shunt malfunction. 28. B. Maintaining the ordered hydration Promoting hydration maintains urine production at a higher rate, which flushes the bladder and prevents urinary stasis and possible infection. 29. C. Taking the clients pedal pulse in the affected limb Monitoring a pedal pulse will assess circulation to the foot. 30. A. Where are you? Where are you? is the best question to elicit information about the clients orientation to place because it encourages a response that can be assessed. 31. D. Bleeding from the venipuncture site

This indicates a fibrinogenemia; massive clotting in the area of the separation has resulted in a lowered circulating fibrinogen. 32. D. blowing pattern Clients should use a blowing pattern to overcome the premature urge to push. 33. A. Cheeseburger and a malted Of the selections offered, this is the highest in calories and protein, which are needed for increased basal metabolic rate and for tissue repair. 34. B. Cyanotic lips and face Central cyanosis (blue lips and face) indicates lowered oxygenation of the blood, caused by either decreased lung expansion or right to left shunting of blood. 35. A. Notify the physician of the findings because the level is dangerously high Levels close to 2 mEq/L are dangerously close to the toxic level; immediate action must be taken. 36. C. Days 15 to 17 Ovulation occurs approximately 14 days before the next menses, about the 16th day in 30 day cycle; the 15th to 17th days would be the best time to avoid sexual intercourse. 37. C. Assure that informed consent has been obtained from the client An invasive procedure such as amniocentesis requires informed consent. 38. D. Prevent development of respiratory distress Respiratory distress or arrest may occur when the serum level of magnesium sulfate reaches 12 to 15 mg/dl; deep tendon reflexes disappear when the serum level is 10 to 12 mg/dl; the drug is withheld in the absence of deep tendon reflexes; the therapeutic serum level is 5 to 8 mg/dl. 39. A. Obtaining the childs daily weight Weight monitoring is the most useful means of assessing fluid balance and changes in the edematous state; 1 liter of fluid weighs about 2.2 pounds. 40. C. Reduces the inflammatory response of tissues Corticosteroids act to decrease inflammation which decreases edema. 41. D. An audible click on hip manipulation With specific manipulation, an audible click may be heard of felt as he femoral head slips into the acetabulum. 42. B. Allow the denial but be available to discuss death This does not remove clients only way of coping, and it permits future movement through the grieving process when the client is ready. 43. B. Divide food into four to six meals a day

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The volume of food in the stomach should be kept small to limit pressure on the cardiac sphincter. 44. B. I feel washed out; there isnt much left The clients statement infers an emptiness with an associated loss. 45. A. Vitamin K is not absorbed Vitamin K, a fat soluble vitamin, is not absorbed from the GI tract in the absence of bile; bile enters the duodenum via the common bile duct. 46. D. Leg weakness with muscle cramps Impulse conduction of skeletal muscle is impaired with decreased potassium levels, muscular weakness and cramps may occur with hypokalemia. 47. D. Simian lines on the hands This is characteristic finding in newborns with Down syndrome. 48. B. Eyes Rheumatoid arthritis can cause inflammation of the iris and ciliary body of the eyes which may lead to blindness. 49. A. Accept the clients decision without discussion This is all the nurse can do until trust is established; facing the client to attend will disrupt the group. 50. D. Provide a simple explanation of the procedure and continue to reassure the client The nurse should offer support and use clear, simple terms to allay clients anxiety. 51. D. If I have difficulty in inserting the irrigating tube into the stoma This occurs with stenosis of the stoma; forcing insertion of the tube could cause injury. 52. C. Blood loss of 850 ml after a vaginal birth Excessive blood loss predisposes the client to an increased risk of infection because of decreased maternal resistance; they expected blood loss is 350 to 500 ml. 53. A. Provide frequent saline mouthwashes This is soothing to the oral mucosa and helps prevent infection. 54. B. Society makes people react in old ways The client is incapable of accepting responsibility for self-created problems and blames society for the behavior. 55. A. Taste and smell Swelling can obstruct nasal breathing, interfering with the senses of taste and smell. 56. A. Fatigue Fatigue is a major problem caused by an increase in waste products because of catabolic processes.

57. A. Offer the client assistance to the bathroom Statistics indicate that the most frequent cause of falls by hospitalized clients is getting up or attempting to get up to the bathroom unassisted. 58. D. Turn completely over, sit momentarily without support, reach to be picked up These abilities are age-appropriate for the 6 month old child. 59. D. Feed the baby on the unaffected breast first until the affected breast heals The most vigorous sucking will occur during the first few minutes of breastfeeding when the infant would be on the unaffected breast; later suckling is less traumatic. 60. D. Place sterile cotton loosely in the external ear of the client This would absorb the drainage without causing further trauma. 61. D. Airing their feelings regarding the transmission of the disease to the child Discussion with parents who have children with similar problems helps to reduce some of their discomfort and guilt. 62. A. Suspicious feelings The nurse must deal with these feelings and establish basic trust to promote a therapeutic milieu. 63. A. Surgical menopause will occur When a bilateral oophorectomy is performed, both ovaries are excised, eliminating ovarian hormones and initiating response. 64. D. Pointing out to the client that death can occur with malnutrition. The client expects the nurse to focus on eating, but the emphasis should be placed on feelings rather than actions. 65. B. Medication is not adequately effective The expected effect should be more than a one point decrease in the pain level. 66. B. Assisting the parents to stimulate their baby through touch, sound, and sight. Stimuli are provided via all the senses; since the infants behavioral development is enhanced through parent-infant interactions, these interactions should be encouraged. 67. D. Recognize himself as an independent person of worth Academic deficits, an inability to function within constraints required of certain settings, and negative peer attitudes often lead to low selfesteem. 68. B. Monitoring the childs blood pressure Because the tumor is of renal origin, the rennin angiotensin mechanism can be involved, and blood pressure monitoring is important. 69. A. Nursing unit manager

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Controlled substance issues for a particular nursing unit are the responsibility of that units nurse manager. 70. D. Encourage coughing, deep breathing, and range of motion to the arm on the affected side All these interventions promote aeration of the re-expanding lung and maintenance of function in the arm and shoulder on the affected side. 71. A. For people to attain their birthrights of health and longevity According to Winslow, all public health efforts are for people to realize their birthrights of health and longevity. 72. C. Swaroops index Swaroops index is the percentage of the deaths aged 50 years or older. Its inverse represents the percentage of untimely deaths (those who died younger than 50 years). 73. D. Public health nursing focuses on preventive, not curative, services. The catchment area in PHN consists of a residential community, many of whom are well individuals who have greater need for preventive rather than curative services. 74. B. Ensure the accessibility and quality of health care Ensuring the accessibility and quality of health care is the primary mission of DOH. 75. B. Efficiency Efficiency is determining whether the goals were attained at the least possible cost. 76. D. Rural Health Unit R.A. 7160 devolved basic health services to local government units (LGUs ). The public health nurse is an employee of the LGU. 77. A. Act 3573 Act 3573, the Law on Reporting of Communicable Diseases, enacted in 1929, mandated the reporting of diseases listed in the law to the nearest health station. 78. A. Primary The purpose of isolating a client with a communicable disease is to protect those who are not sick (specific disease prevention). 79. B. It provides an opportunity to do first hand appraisal of the home situation. Choice A is not correct since a home visit requires that the nurse spend so much time with the family. Choice C is an advantage of a group conference, while choice D is true of a clinic consultation. 80. B. Should minimize if not totally prevent the spread of infection. Bag technique is performed before and after handling a client in the home to prevent transmission of infection to and from the client. 81. A. Bag technique is performed before and after handling a client in the home to

prevent transmission of infection to and from the client. Path Goal theory according to House and associates rewards good performance so that others would do the same. 82. D. Inspires others with vision Inspires others with a vision is characteristic of a transformational leader. He is focused more on the day-to-day operations of the department/unit. 83. A. Psychological and sociological needs are emphasized. When the functional method is used, the psychological and sociological needs of the patients are neglected; the patients are regarded as tasks to be done 84. B. Preparing a nursing care plan in collaboration with the patient The best source of information about the priority needs of the patient is the patient himself. Hence using a nursing care plan based on his expressed priority needs would ensure meeting his needs effectively. 85. C. Unity of command The principle of unity of command means that employees should receive orders coming from only one manager and not from two managers. This averts the possibility of sowing confusion among the members of the organization. 86. A. Increase the patient satisfaction rate Goal is a desired result towards which efforts are directed. Options AB, C and D are all objectives which are aimed at specific end. 87. A. Uses visioning as the essence of leadership Transformational leadership relies heavily on visioning as the core of leadership. 88. C. Avoidance This strategy shuns discussing the issue head-on and prefers to postpone it to a later time. In effect the problem remains unsolved and both parties are in a lose-lose situation. 89. A. Staffing Staffing is a management function involving putting the best people to accomplish tasks and activities to attain the goals of the organization. 90. B. Decentralized Decentralized structures allow the staff to make decisions on matters pertaining to their practice and communicate in downward, upward, lateral and diagonal flow. 91. D. end each entry with the nurse's signature and title. The end of each entry should include the nurse's signature and title; the signature holds the nurse accountable for the recorded information. Erasing errors in documentation on a legal document such as a client's chart isn't permitted by law. Because a client's medical record is considered a legal document, the nurse should make all entries in ink. The nurse is accountable for the

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information recorded and therefore shouldn't leave any blank lines in which another health care worker could make additions. 92. A. Allergies and socioeconomic status General background data consist of such components as allergies, medical history, habits, socioeconomic status, lifestyle, beliefs, and sensory deficits. Urine output, gastric reflex, and bowel habits are significant only if a disease affecting these functions is present. 93. C. I.V. cannula insertion Caregivers must use surgical asepsis when performing wound care or any procedure in which a sterile body cavity is entered or skin integrity is broken. To achieve surgical asepsis, objects must be rendered or kept free of all pathogens. Inserting an I.V. cannula requires surgical asepsis because it disrupts skin integrity and involves entry into a sterile cavity (a vein). The other options are used to ensure medical asepsis or clean technique to prevent the spread of infection. The GI tract isn't sterile; therefore, irrigating a nasogastric tube or a colostomy requires only clean technique. 94. B. Pouring solution onto a sterile field cloth Pouring solution onto a sterile field cloth violates surgical asepsis because moisture penetrating the cloth can carry microorganisms to the sterile field via capillary action. The other options are practices that help ensure surgical asepsis. 95. C. Impaired gas exchange The client has a below-normal value for the partial pressure of arterial oxygen (PaO2) and an above-normal value for the partial pressure of arterial carbon dioxide (PaCO2), supporting the nursing diagnosis of Impaired gas exchange. ABG values can't indicate a diagnosis of Fluid volume deficit (or excess) or Risk for deficient fluid volume. Metabolic acidosis is a medical, not nursing, diagnosis; in any event, these ABG values indicate respiratory, not metabolic, acidosis. 96. A. Stream seeding Stream seeding is done by putting tilapia fry in streams or other bodies of water identified as breeding places of the Anopheles mosquito. 97. B. Severe dehydration The order of priority in the management of severe dehydration is as follows: intravenous fluid therapy, referral to a facility where IV fluids can be initiated within 30 minutes, Oresol/nasogastric tube, Oresol/orem. When the foregoing measures are not possible or effective, tehn urgent referral to the hospital is done. 98. A. Inability to drink A sick child aged 2 months to 5 years must be referred urgently to a hospital if he/she has one or more of the following signs: not able to feed or drink, vomits everything, convulsions, abnormally sleepy or difficult to awaken. 99. A. Sugar

R.A. 8976 mandates fortification of rice, wheat flour, sugar and cooking oil with Vitamin A, iron and/or iodine. 100. A. Palms The anatomic characteristics of the palms allow a reliable and convenient basis for examination for pallor. 1. A woman in a child bearing age receives a rubella vaccination. Nurse Joy would give her which of the following instructions? a. Refrain from eating eggs or egg products for 24 hours b. Avoid having sexual intercourse c. Dont get pregnant at least 3 months d. Avoid exposure to sun 2. Jonas who is diagnosed with encephalitis is under the treatment of Mannitol. Which of the following patient outcomes indicate to Nurse Ronald that the treatment of Mannitol has been effective for a patient that hasincreased intracranial pressure? a. Increased urinary output b. Decreased RR c. Slowed papillary response d. Decreased level of consciousness 3. Mary asked Nurse Maureen about the incubation period of rabies. Which statement by the Nurse Maureen is appropriate? a. Incubation period is 6 months b. Incubation period is 1 week c. Incubation period is 1 month d. Incubation period varies depending on the site of the bite 4. Which of the following should Nurse Cherry do first in taking care of a male client with rabies? a. Encourage the patient to take a bath b. Cover IV bottle with brown paper bag c. Place the patient near the comfort room

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d. Place the patient near the door 5. Which of the following is the screening test for dengue hemorrhagic fever? a. Complete blood count

d. 4 year old girl who lives next door 10. What is the primary prevention of leprosy? a. Nutrition

b. ELISA b. Vitamins c. Rumpel-leede test c. BCG vaccination d. Sedimentation rate d. DPT vaccination 6. Mr. Dela Rosa is suspected to have malaria after a business trip in Palawan. The most important diagnostic test in malaria is: a. WBC count b. Cholera b. Urinalysis c. Klebs-loeffler bacillus c. ELISA d. Spirochete d. Peripheral blood smear 7. The Nurse supervisor is planning for patients assignment for the AM shift. The nurse supervisor avoids assigning which of the following staff members to a client with herpes zoster? a. Nurse who never had chicken pox b. Nurse who never had roseola c. Nurse who never had german measles d. Nurse who never had mumps 8. Clarissa is 7 weeks pregnant. Further examination revealed that she is susceptible to rubella. When would be the most appropriate for her to receive rubella immunization? a. At once b. During 2nd trimester c. During 3rd trimester d. After the delivery of the baby 9. A female child with rubella should be isolated from a: a. 21 year old male cousin living in the same house b. 18 year old sister who recently got married c. 11 year old sister who had rubeola during childhood 12. Nurse Ron performed mantoux skin test today (Monday) to a male adult client. Which statement by the client indicates that he understood the instruction well? a. I will come back later b. I will come back next month c. I will come back on Friday d. I will come back on Wednesday, same time, to read the result 13. A male client had undergone Mantoux skin test. Nurse Ronald notes an 8mm area of indurations at the site of the skin test. The nurse interprets the result as: a. Negative b. Uncertain and needs to be repeated c. Positive d. Inconclusive 14. Tony will start a 6 month therapy with Isoniazid (INH). Nurse Trish plans to teach the client to: a. Use alcohol moderately b. Avoid vitamin supplements while o therapy c. Incomplete intake of dairy products 11. A bacteria which causes diphtheria is also known as? a. Amoeba

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d. May be discontinued if symptoms subsides 15. Which is the primary characteristic lesion of syphilis? a. Sore eyes

d. Burn 21. Which of the following is a live attenuated bacterial vaccine? a. BCG b. OPV

b. Sore throat c. Measles c. Chancroid d. None of the above d. Chancre 22. EPI is based on? 16. What is the fast breathing of Jana who is 3 weeks old? a. 60 breaths per minute b. 40 breaths per minute c. 10 breaths per minute d. 20 breaths per minute 17. Which of the following signs and symptoms indicate some dehydration? a. Drinks eagerly b. Restless and irritable c. Unconscious d. A and B 18. What is the first line for dysentery? a. Amoxicillin b. Tetracycline c. Cefalexin d. Cotrimoxazole 19. In home made oresol, what is the ratio of salt and sugar if you want to prepare with 1 liter of water? a. 1 tbsp. salt and 8 tbsp. sugar b. 1 tbsp. salt and 8 tsp. sugar c. 1 tsp. salt and 8 tsp. sugar d. 8 tsp. salt and 8 tsp. sugar 20. Gentian Violet is used for: a. Wound b. Controlling b. Umbilical infections c. Organizing c. Ear infections d. Planning a. Basic health services b. Scope of community affected c. Epidemiological situation d. Research studies 23. TT? provides how many percentage of protection against tetanus? a. 100 b. 99 c. 80 d. 90 24. Temperature of refrigerator to maintain potency of measles and OPV vaccine is: a. -3c to -8c b. -15c to -25c c. +15c to +25c d. +3c to +8c 25. Diptheria is a: a. Bacterial toxin b. Killed bacteria c. Live attenuated d. Plasma derivatives 26. Budgeting is under in which part of management process? a. Directing

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27. Time table showing planned work days and shifts of nursing personnel is: a. Staffing b. Schedule c. Scheduling d. Planning 28. A force within an individual that influences the strength of behavior? a. Motivation b. Envy c. Reward d. Self-esteem 29. To be the leading hospital in the Philippines is best illustrate in: a. Mission b. Philosophy c. Vision d. Objective 30. It is the professionally desired norms against which a staff performance will be compared? a. Job descriptions b. Survey c. Flow chart d. Standards 31. Reprimanding a staff nurse for work that is done incorrectly is an example of what type of reinforcement? a. Feedback b. Positive reinforcement

d. Demographic 33. A researcher that makes a generalization based on observations of an individuals behavior is said to be which type of reasoning: a. Inductive b. Logical c. Illogical d. Deductive 34. The balance of a researchs benefit vs. its risks to the subject is: a. Analysis b. Risk-benefit ratio c. Percentile d. Maximum risk 35. An individual/object that belongs to a general population is a/an: a. Element b. Subject c. Respondent d. Author 36. An illustration that shows how the members of an organization are connected: a. Flowchart b. Bar graph c. Organizational chart d. Line graph 37. The first college of nursing that was established in the Philippines is: a. Fatima University

c. Performance appraisal b. Far Eastern University d. Negative reinforcement c. University of the East 32. Questions that are answerable only by choosing an option from a set of given alternatives are known as? a. Survey a. France b. Close ended b. Britain c. Questionnaire d. University of Sto. Tomas 38. Florence nightingale is born on:

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c. U.S d. Italy 39. Objective data is also called: a. Covert b. Overt c. Inference d. Evaluation 40. An example of subjective data is: a. Size of wounds b. VS c. Lethargy d. The statement of patient My hand is painful 41. What is the best position in palpating the breast? a. Trendelenburg b. Side lying c. Supine d. Lithotomy 42. When is the best time in performing breast self examination? a. 7 days after menstrual period b. 7 days before menstrual period c. 5 days after menstrual period d. 5 days before menstrual period 43. Which of the following should be given the highest priority before performing physical examination to a patient? a. Preparation of the room b. Preparation of the patient c. Preparation of the nurse d. Preparation of environment 44. It is a flip over card usually kept in portable file at nursing station. a. Nursing care plan b. Medicine and treatment record

c. Kardex d. TPR sheet 45. Jose has undergone thoracentesis. The nurse in charge is aware that the best position for Jose is: a. Semi fowlers b. Low fowlers c. Side lying, unaffected side d. Side lying, affected side 46. The degree of patients abdominal distension may be determined by: a. Auscultation b. Palpation c. Inspection d. Percussion 47. A male client is addicted with hallucinogen. Which physiologic effect should the nurse expect? a. Bradyprea b. Bradycardia c. Constricted pupils d. Dilated pupils 48. Tristan a 4 year old boy has suffered from full thickness burns of the face, chest and neck. What will be the priority nursing diagnosis? a. Ineffective airway clearance related to edema b. Impaired mobility related to pain c. Impaired urinary elimination related to fluid loss d. Risk for infection related to epidermal disruption 49. In assessing a clients incision 1 day after the surgery, Nurse Betty expect to see which of the following as signs of a local inflammatory response? a. Greenish discharge b. Brown exudates at incision edges c. Pallor around sutures

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d. Redness and warmth 50. Nurse Ronald is aware that the amiotic fluid in the third trimester weighs approximately: a. 2 kilograms b. 1 kilograms c. 100 grams d. 1.5 kilograms 51. After delivery of a baby girl. Nurse Gina examines the umbilical cord and expects to find a cord to: a. Two arteries and two veins b. One artery and one vein c. Two arteries and one vein d. One artery and two veins 52. Myrna a pregnant client reports that her last menstrual cycle is July 11, her expected date of birth is a. November 4 b. November 11 c. April 4 d. April 18

a. Supine b. Left side lying c. Trendelinburg d. Semi-fowlers 56. Nurse Hazel knows that Myrna understands her condition well when she remarks that urinary frequency is caused by: a. Pressure caused by the ascending uterus b. Water intake of 3L a day c. Effect of cold weather d. Increase intake of fruits and vegetables 57. How many ml of blood is loss during the first 24 hours post delivery of Myrna? a. 100 b. 500 c. 200 d. 400 58. Which of the following hormones stimulates the secretion of milk? a. Progesterone

53. Which of the following is not a good source of iron? a. Butter b. Pechay c. Grains d. Beef 54. Maureen is admitted with a diagnosis of ectopic pregnancy. Which of the following would you anticipate? a. NPO b. Bed rest c. Immediate surgery d. Enema 55. Gina a postpartum client is diagnosed with endometritis. Which position would you expect to place her based on this diagnosis?

b. Prolactin c. Oxytocin d. Estrogen 59. Nurse Carla is aware that Mylas second stage of labor is beginning when the following assessment is noted: a. Bay of water is broken b. Contractions are regular c. Cervix is completely dilated d. Presence of bloody show 60. The leaking fluid is tested with nitrazine paper. Nurse Kelly confirms that the clients membrane have ruptures when the paper turns into a: a. Pink b. Violet

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c. Green d. Blue 61. After amniotomy, the priority nursing action is: a. Document the color and consistency of amniotic fluid b. Listen the fetal heart tone c. Position the mother in her left side d. Let the mother rest 62. Which is the most frequent reason for postpartum hemorrhage? a. Perineal lacerations b. Frequent internal examination (IE) c. CS d. Uterine atomy 63. On 2nd postpartum day, which height would you expect to find the fundus in a woman who has had a caesarian birth? a. 1 finger above umbilicus b. 2 fingers above umbilicus c. 2 fingers below umbilicus d. 1 finger below umbilicus 64. Which of the following criteria allows Nurse Kris to perform home deliveries? a. Normal findings during assessment b. Previous CS c. Diabetes history d. Hypertensive history 65. Nurse Carla is aware that one of the following vaccines is done by intramuscular (IM) injection? a. Measles

a. RA 8860 b. RA 2777 c. RI 8172 d. RR 6610 67. Nurse John is aware that the herbal medicine appropriate for urolithiasis is: a. Akapulco b. Sambong c. Tsaang gubat d. Bayabas 68. Community/Public health bag is defined as: a. An essential and indispensable equipment of the community health nurse during home visit b. It contains drugs and equipment used by the community health nurse c. Is a requirement in the health center and for home visit d. It is a tool used by the community health nurse in rendering effective procedures during home visit 69. TT4 provides how many percentage of protection against tetanus? a. 70 b. 80 c. 90 d. 99 70. Third postpartum visit must be done by public health nurse: a. Within 24 hours after delivery b. After 2-4 weeks c. Within 1 week d. After 2 months

b. OPV c. BCG d. Tetanus toxoid 66. Asin law is on which legal basis: 71. Nurse Candy is aware that the family planning method that may give 98% protection to another pregnancy to women a. Pills b. Tubal ligation

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c. Lactational Amenorrhea method (LAM) d. IUD

a. Narcan b. Digoxin c. Acetylcysteine

72. Which of the following is not a part of IMCI case management process a. Counsel the mother b. Identify the illness c. Assess the child d. Treat the child 73. If a young child has pneumonia when should the mother bring him back for follow up? a. After 2 days b. In the afternoon c. After 4 days d. After 5 days 74. It is the certification recognition program that develop and promotes standard for health facilities: a. Formula b. Tutok gamutan c. Sentrong program movement d. Sentrong sigla movement 75. Baby Marie was born May 23, 1984. Nurse John will expect finger thumb opposition on: a. April 1985 b. February 1985 c. March 1985 d. June 1985 76. Baby Reese is a 12 month old child. Nurse Oliver would anticipate how many teeth? a. 9 b. 7 c. 8 d. 6 77. Which of the following is the primary antidote for Tylenol poisoning?

d. Flumazenil 78. A male child has an intelligence quotient of approximately 40. Which kind of environment and interdisciplinary program most likely to benefit this child would be best described as: a. Habit training b. Sheltered workshop c. Custodial d. Educational 79. Nurse Judy is aware that following condition would reflect presence of congenital G.I anomaly? a. Cord prolapse b. Polyhydramios c. Placenta previa d. Oligohydramios 80. Nurse Christine provides health teaching for the parents of a child diagnosed with celiac disease. Nurse Christine teaches the parents to include which of the following food items in the childs diet: a. Rye toast b. Oatmeal c. White bread d. Rice 81. Nurse Randy is planning to administer oral medication to a 3 year old child. Nurse Randy is aware that the best way to proceed is by: a. Would you like to drink your medicine? b. If you take your medicine now, Ill give you lollipop c. See the other boy took his medicine? Now its your turn. d. Heres your medicine. Would you like a mango or orange juice?

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82. At what age a child can brush her teeth without help? a. 6 years

b. License Number c. Date of Application d. Signature of PRC chairperson

b. 7 years c. 5 years d. 8 years 83. Ribivarin (Virazole) is prescribed for a female hospitalized child with RSV. Nurse Judy prepare this medication via which route? a. Intra venous b. Oral c. Oxygen tent d. Subcutaneous b. Autonomy 84. The present chairman of the Board of Nursing in the Philippines is: a. Maria Joanna Cervantes b. Carmencita Abaquin c. Leonor Rosero d. Primitiva Paquic a. Governance 85. The obligation to maintain efficient ethical standards in the practice of nursing belong to this body: a. BON d. Res ipsa loquitor b. ANSAP c. PNA d. RN a. Fidelity 86. A male nurse was found guilty of negligence. His license was revoked. Reissuance of revoked certificates is after how many years? a. 1 year b. 2 years c. 3 years d. 4 years 87. Which of the following information cannot be seen in the PRC identification card? a. Registration Date b. Autonomy c. Veracity d. Confidentiality 92. This quality is being demonstrated by Nurse Ron who raises the side rails of a confused and disoriented patient? a. Responsibility b. Resourcefulness c. Autonomy d. Prudence 91. Being on time, meeting deadlines and completing all scheduled duties is what virtue? b. Respondent superior c. Force majeure c. Fidelity d. Beneficence 90. A male patient complained because his scheduled surgery was cancelled because of earthquake. The hospital personnel may be excused because of: 88. Breastfeeding is being enforced by milk code or: a. EO 51 b. R.A. 7600 c. R.A. 6700 d. P.D. 996 89. Self governance, ability to choose or carry out decision without undue pressure or coercion from anyone: a. Veracity

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93. Which of the following is formal continuing education? a. Conference b. Enrollment in graduate school c. Refresher course d. Seminar 94. The BSN curriculum prepares the graduates to become? a. Nurse generalist b. Nurse specialist c. Primary health nurse d. Clinical instructor 95. Disposal of medical records in government hospital/institutions must be done in close coordination with what agency? a. Department of Health b. Records Management Archives Office c. Metro Manila Development Authority d. Bureau of Internal Revenue 96. Nurse Jolina must see to it that the written consent of mentally ill patients must be taken from: a. Nurse b. Priest c. Family lawyer d. Parents/legal guardians 97. When Nurse Clarence respects the clients self-disclosure, this is a gauge for the nurses a. Respectfulness b. Loyalty c. Trustworthiness d. Professionalism 98. The Nurse is aware that the following tasks can be safely delegated by the nurse to a non-nurse health worker except: a. Taking vital signs

b. Change IV infusions c. Transferring the client from bed to chair d. Irrigation of NGT 99. During the evening round Nurse Tina saw Mr. Toralba meditating and afterwards started singing prayerful hymns. What would be the best response of Nurse Tina? a. Call the attention of the client and encourage to sleep b. Report the incidence to head nurse c. Respect the clients action d. Document the situation 100. In caring for a dying client, you should perform which of the following activities a. Do not resuscitate b. Assist client to perform ADL c. Encourage to exercise d. Assist client towards a peaceful death 101. The Nurse is aware that the ability to enter into the life of another person and perceive his current feelings and their meaning is known: a. Belongingness b. Genuineness c. Empathy d. Respect 102. The termination phase of the NPR is best described one of the following: a. Review progress of therapy and attainment of goals b. Exploring the clients thoughts, feelings and concerns c. Identifying and solving patients problem d. Establishing rapport 103. During the process of cocaine withdrawal, the physician orders which of the following:

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a. Haloperidol (Haldol) b. Imipramine (Tofranil) c. Benztropine (Cogentin) d. Diazepam (Valium) 104. The nurse is aware that cocaine is classified as: a. Hallucinogen b. Psycho stimulant c. Anxiolytic d. Narcotic 105. In community health nursing, it is the most important risk factor in the development of mental illness? a. Separation of parents b. Political problems c. Poverty d. Sexual abuse 106. All of the following are characteristics of crisis except a. The client may become resistive and active in stopping the crisis b. It is self-limiting for 4-6 weeks c. It is unique in every individual d. It may also affect the family of the client 107. Freud states that temper tantrums is observed in which of the following: a. Oral b. Anal c. Phallic d. Latency 108. The nurse is aware that ego development begins during: a. Toddler period b. Preschool age c. School age d. Infancy

109. Situation: A 19 year old nursing student has lost 36 lbs for 4 weeks. Her parents brought her to the hospital for medical evaluation. The diagnosis was ANOREXIA NERVOSA. The Primary gain of a client with anorexia nervosa is: a. Weight loss b. Weight gain c. Reduce anxiety d. Attractive appearance 110. The nurse is aware that the primary nursing diagnosis for the client is: a. Altered nutrition : less than body requirement b. Altered nutrition : more than body requirement c. Impaired tissue integrity d. Risk for malnutrition 111. After 14 days in the hospital, which finding indicates that her condition in improving? a. She tells the nurse that she had no idea that she is thin b. She arrives earlier than scheduled time of group therapy c. She tells the nurse that she eat 3 times or more in a day d. She gained 4 lbs in two weeks 112. The nurse is aware that ataractics or psychic energizers are also known as: a. Anti manic b. Anti depressants c. Antipsychotics d. Anti anxiety 113. Known as mood elevators: a. Anti depressants b. Antipsychotics c. Anti manic d. Anti anxiety 114. The priority of care for a client with Alzheimers disease is

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a. Help client develop coping mechanism b. Encourage to learn new hobbies and interest c. Provide him stimulating environment d. Simplify the environment to eliminate the need to make chores 115. Autism is diagnosed at: a. Infancy b. 3 years old c. 5 years old d. School age 116. The common characteristic of autism child is: a. Impulsitivity b. Self destructiveness

120. The appropriate nutrition for Bipolar I disorder, in manic phase is: a. Low fat, low sodium b. Low calorie, high fat c. Finger foods, high in calorie d. Small frequent feedings 121. Which of the following activity would be best for a depressed client? a. Chess b. Basketball c. Swimming d. Finger painting 122. The nurse is aware that clients with severe depression, possess which defense mechanism: a. Introjection b. Suppression

c. Hostility c. Repression d. Withdrawal d. Projection 117. The nurse is aware that the most common indication in using ECT is: a. Schizophrenia b. Bipolar c. Anorexia Nervosa d. Depression 118. A therapy that focuses on here and now principle to promote self-acceptance? a. Gestalt therapy b. Cognitive therapy c. Behavior therapy d. Personality therapy 119. A client has many irrational thoughts. The goal of therapy is to change her: a. Personality b. Communication b. Strain urine c. Behavior c. Limit fluids d. Cognition 123. Nurse John is aware that self mutilation among Bipolar disorder patients is a means of: a. Overcoming fear of failure b. Overcoming feeling of insecurity c. Relieving depression d. Relieving anxiety 124. Which of the following may cause an increase in the cystitis symptoms? a. Water b. Orange juice c. Coffee d. Mango juice 125. In caring for clients with renal calculi, which is the priority nursing intervention? a. Record vital signs

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d. Administer analgesics as prescribed 126. In patient with renal failure, the diet should be: a. Low protein, low sodium, low potassium b. Low protein, high potassium c. High carbohydrate, low protein d. High calcium, high protein 127. Which of the following cannot be corrected by dialysis? a. Hypernatremia b. Hyperkalemia c. Elevated creatinine d. Decreased hemoglobin 128. Tony with infection is receiving antibiotic therapy. Later the client complaints of ringing in the ears. This ototoxicity is damage to: a. 4th CN b. 8th CN c. 7th CN d. 9
th

131. During acute gout attack, the nurse administer which of the following drug: a. Prednisone (Deltasone) b. Colchicines c. Aspirin d. Allopurinol (Zyloprim) 132. Information in the patients chart is inadmissible in court as evidence when: a. The client objects to its use b. Handwriting is not legible c. It has too many unofficial abbreviations d. The clients parents refuses to use it 133. Nurse Karen is revising a client plan of care. During which step of the nursing process does such revision take place? a. Planning b. Implementation c. Diagnosing d. Evaluation 134. When examining a client with abdominal pain, Nurse Hazel should assess: a. Symptomatic quadrant either second or first b. The symptomatic quadrant last c. The symptomatic quadrant first

CN

129. Nurse Emma provides teaching to a patient with recurrent urinary tract infection includes the following: a. Increase intake of tea, coffee and colas b. Void every 6 hours per day

d. Any quadrant c. Void immediately after intercourse d. Take tub bath everyday 130. Which assessment finding indicates circulatory constriction in a male client with a newly applied long leg cast? a. Blanching or cyanosis of legs b. Complaints of pressure or tightness c. Inability to move toes d. Numbness of toes 135. How long will nurse John obtain an accurate reading of temperature via oral route? a. 3 minutes b. 1 minute c. 8 minutes d. 15 minutes 136. The one filing the criminal care against an accused party is said to be the? a. Guilty

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b. Accused c. Plaintiff d. Witness

d. External ear 142. When performing Webers test, Nurse Rosean expects that this client will hear a. On unaffected side

137. A male client has a standing DNR order. He then suddenly stopped breathing and you are at his bedside.You would: a. Call the physician b. Stay with the client and do nothing c. Call another nurse d. Call the family 138. The ANA recognized nursing informatics heralding its establishment as a new field in nursing during what year? a. 1994

b. Longer through bone than air conduction c. On affected side by bone conduction d. By neither bone or air conduction 143. Toy with a tentative diagnosis of myasthenia gravis is admitted for diagnostic make up. Myasthenia gravis can confirmed by: a. Kernigs sign b. Brudzinskis sign c. A positive sweat chloride test

b. 1992 c. 2000 d. 2001 139. When is the first certification of nursing informatics given? a. 1990-1993 b. 2001-2002 c. 1994-1996 d. 2005-2008 140. The nurse is assessing a female client with possible diagnosis of osteoarthritis. The most significant risk factor for osteoarthritis is: a. Obesity b. Race c. Job d. Age 141. A male client complains of vertigo. Nurse Bea anticipates that the client may have a problem with which portion of the ear? a. Tymphanic membranes b. Inner ear c. Auricle d. A positive edrophonium (Tensilon) test 144. A male client is hospitalized with Guillain-Barre Syndrome. Which assessment finding is the most significant? a. Even, unlabored respirations b. Soft, non distended abdomen c. Urine output of 50 ml/hr d. Warm skin 145. For a female client with suspected intracranial pressure (ICP), a most appropriate respiratory goal is: a. Maintain partial pressure of arterial oxygen (Pa O2) above 80mmHg b. Promote elimination of carbon dioxide c. Lower the PH d. Prevent respiratory alkalosis 146. Which nursing assessment would identify the earliest sign of ICP? a. Change in level of consciousness b. Temperature of over 103F c. Widening pulse pressure

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d. Unequal pupils 147. The greatest danger of an uncorrected atrial fibrillation for a male patient will be which of the following: a. Pulmonary embolism b. Cardiac arrest c. Thrombus formation d. Myocardial infarction 148. Linda, A 30 year old post hysterectomy client has visited the health center. She inquired about BSE and asked the nurse when BSE should be performed. You answered that the BSE is best performed: a. 7 days after menstruation b. At the same day each month c. During menstruation d. Before menstruation 149. An infant is ordered to recive 500 ml of D5NSS for 24 hours. The Intravenous drip is running at 60 gtts/min. How many drops per minute should the flow rate be? a. 60 gtts/min. b. 21 gtts/min c. 30 gtts/min d. 15 gtts/min 150. Mr. Gutierrez is to receive 1 liter of D5RL to run for 12 hours. The drop factor of the IV infusion set is 10 drops per minute. Approximately how many drops per minutes should the IV be regulated? a. 13-14 drops b. 17-18 drops c. 10-12 drops d. 15-16 drops 2. A nurse manager assigned a registered nurse from telemetry unit to the pediatrics unit. There were three patients assigned to the RN. Which of the following patients should not be assigned to the floated nurse? A) A 9-year-old child diagnosed with rheumatic fever B) A young infant after pyloromyotomy C) A 4-year-old with VSD following cardiac catheterization D) A 5-month-old with Kawasaki disease

Board Exam Nursing Test I NLE Scope of this Nursing Test I is parallel to the NP1 NLE Coverage: Foundation of Nursing Nursing Research Professional Adjustment Leadership and Management

1. The registered nurse is planning to delegate tasks to unlicensed assistive personnel (UAP). Which of the following task could the registered nurse safely assigned to a UAP? A) Monitor the I&O of a comatose toddler client with salicylate poisoning B) Perform a complete bed bath on a 2-year-old with multiple injuries from a serious fall C) Check the IV of a preschooler with Kawasaki disease D) Give an outmeal bath to an infant with eczema

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3. A nurse in charge in the pediatric unit is absent. The nurse manager decided to assign the nurse in the obstetrics unit to the pediatrics unit. Which of the following patients could the nurse manager safely assign to the float nurse? A) A child who had multiple injuries from a serious vehicle accident B) A child diagnosed with Kawasaki disease and with cardiac complications C) A child who has had a nephrectomy for Wilms tumor D) A child receiving an IV chelating therapy for lead poisoning 4. The registered nurse is planning to delegate task to a certified nursing assistant. Which of the following clients should not be assigned to a CAN? A) A client diagnosed with diabetes and who has an infected toe B) A client who had a CVA in the past two months C) A client with Chronic renal failure D) A client with chronic venous insufficiency 5. The nurse in the medication unit passes the medications for all the clients on the nursing unit. The head nurse is making rounds with the physician and coordinates clients activities with other departments. The nurse assistant changes the bed lines and answers call lights. A second nurse is assigned for changing wound dressings; a licensed practitioner nurse takes vital signs and bathes theclients. This illustrates of what method of nursing care? A) Case management method B) Primary nursing method C) Team method D) Functional method 6. A registered nurse has been assigned to six clients on the 12-hour shift. The RN is responsible for every aspect of care such as formulating the care of plan, intervention and evaluating the care during her shift. At the end of her shift, the RN will pass this same task to the next RN in charge. This nursing care illustrates of what kind of method? A) primary nursing method B) case method C) team method D) functional method 7. A newly hired nurse on an adult medicine unit with 3 months experience was asked to float to pediatrics. The nurse hesitates to perform pediatric skills and receive an interesting assignment that feels overwhelming. The nurse should: A) resign on the spot from the nursing position and apply for a position that does not require floating

B) Inform the nursing supervisor and the charge nurse on the pediatric floor about the nurses lack of skill and feelings of hesitations and request assistance C) Ask several other nurses how they feel about pediatrics and find someone else who is willing to accept the assignment D) Refuse the assignment and leave the unit requesting a vacation a day 8. An experienced nurse who voluntarily trained a less experienced nurse with the intention of enhancing the skills and knowledge and promoting professional advancement to the nurse is called a: A) mentor B) team leader C) case manager D) change agent 9. The pediatrics unit is understaffed and the nurse manager informs the nurses in the obstetrics unit that she is going to assign one nurse to float in the pediatric units. Which statement by the designated float nurse may put her job at risk? A) I do not get along with one of the nurses on the pediatrics unit B) I have a vacation day coming and would like to take that now C) I do not feel competent to go and work on that area D) I am afraid I will get the most serious clients in the unit 10. The newly hired staff nurse has been working on a medical unit for 3 weeks. The nurse manager has posted the team leader assignments for the following week. The new staff knows that a major responsibility of the team leader is to: A) Provide care to the most acutely ill client on the team B) Know the condition and needs of all the patients on the team C) Document the assessments completed by the team members D) Supervise direct care by nursing assistants 11. A 15-year-old girl just gave birth to a baby boy who needs emergency surgery. The nurse prepared the consent form and it should be signed by: A) The Physician B) The Registered Nurse caring for the client C) The 15-year-old mother of the baby boy D) The mother of the girl 12. A nurse caring to a client with Alzheimers disease overheard a family member say to the client, if you pee one more time, I wont give

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you any more food and drinks. What initial action is best for the nurse to take? A) Take no action because it is the family member saying that to the client B) Talk to the family member and explain that what she/he has said is not appropriate for the client C) Give the family member the number for an Elder Abuse Hot line D) Document what the family member has said 13. Which is true about informed consent? A) A nurse may accept responsibility signing a consent form if the client is unable B) Obtaining consent is not the responsibility of the physician C) A physician will not subject himself to liability if he withholds any facts that are necessary to form the basis of an intelligent consent D) If the nurse witnesses a consent for surgery, the nurse is, in effect, indicating that the signature is that of the purported person and that the persons condition is as indicated at the time of signing 14. A mother in labor told the nurse that she was expecting that her baby has no chance to survive and expects that the baby will be born dead. The mother accepts the fate of the baby and informs the nurse that when the baby is born and requires resuscitation, the mother refuses any treatment to her baby and expresses hostility toward the nurse while the pediatric team is taking care of the baby. The nurse is legally obligated to: A) Notify the pediatric team that the mother has refused resuscitation and any treatment for the baby and take the baby to the mother B) Get a court order making the baby a ward of the court C) Record the statement of the mother, notify the pediatric team, and observe carefully for signs of impaired bonding and neglect as a reasonable suspicion of child abuse D) Do nothing except record the mothers statement in the medical record 15. The hospitalized client with a chronic cough is scheduled for bronchoscopy. The nurse is tasks to bring the informed consent document into the clients room for a signature. The client asks the nurse for details of the procedure and demands an explanation why the process of informed consent is necessary. The nurse responds that informed consent means: A) The patient releases the physician from all responsibility for the procedure. B) The immediate family may make decision against the patients will. C) The physician must give the client or surrogates enough information to make health care judgments consistent with their values and goals. D) The patient agrees to a procedure ordered by

the physician even if the client does not understand what the outcome will be. 16. A hospitalized client with severe necrotizing ulcer of the lower leg is schedule for an amputation. The client tells the nurse that he will not sign the consent form and he does not want any surgery or treatment because of religious beliefs about reincarnation. What is the role of the RN? A) call a family meeting B) discuss the religious beliefs with the physician C) encourage the client to have the surgery D) inform the client of other options 17. While in the hospital lobby, the RN overhears the three staff discussing the health condition of her client. What would be the appropriate nursing action for the RN to take? A) Tell them it is not appropriate to discuss the condition of the client B) Ignore them, because it is their right to discuss anything they want to C) Join in the conversation, giving them supportive input about the case of the client D) Report this incident to the nursing supervisor 18. A staff nurse has had a serious issue with her colleague. In this situation, it is best to: A) Discuss this with the supervisor B) Not discuss the issue with anyone. It will probably resolve itself C) Try to discuss with the colleague about the issue and resolve it when both are calmer D) Tell other members of the network what the team member did 19. The nurse is caring to a client who just gave birth to a healthy baby boy. The nurse may not disclose confidential information when: A) The nurse discusses the condition of the client in a clinical conference with other nurses B) The client asks the nurse to discuss the her condition with the family C) The father of a woman who just delivered a baby is on the phone to find out the sex of the baby D) A researcher from an institutionally approved research study reviews the medical record of a patient 20. A 17-year-old married client is scheduled for surgery. The nurse taking care of the client realizes that consent has not been signed after preoperative medications were given. What should the nurse do? A) Call the surgeon B) Ask the spouse to sign the consent C) Obtain a consent from the client as soon as possible

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D) Get a verbal consent from the parents of the client 21. A 12-year-old client is admitted to the hospital. The physician ordered Dilantin to the client. In administering IV phenytoin (Dilantin) to a child, the nurse would be most correct in mixing it with: A) Normal Saline B) Heparinized normal saline C) 5% dextrose in water D) Lactated Ringers solution 22. The nurse is caring to a client who is hypotensive. Following a large hematemesis, how should the nurse position the client? A) Feet and legs elevated 20 degrees, trunk horizontal, head on small pillow B) Low Fowlers with knees gatched at 30 degrees C) Supine with the head turned to the left D) Bed sloped at a 45 degree angle with the head lowest and the legs highest 23. The client is brought to the emergency department after a serious accident. What would be the initial nursing action of the nurse to the client? A) assess the level of consciousness and circulation B) check respirations, circulation, neurological response C) align the spine, check pupils, check for hemorrhage D) check respiration, stabilize spine, check circulation 24. A nurse is assigned to care to a client with Parkinsons disease. What interventions are important if the nurse wants to improve nutrition and promote effective swallowing of the client? A) Eat solid food B) Give liquids with meals C) Feed the client D) Sit in an upright position to eat 25. During tracheal suctioning, the nurse should implement safety measures. Which of the following should the nurse implements? A) limit suction pressure to 150-180 mmHg B) suction for 15-20 seconds C) wear eye goggles D) remove the inner cannula 26. The nurse is conducting a discharge instructions to a client diagnosed with diabetes. What sign of hypoglycemia should be taught to a client?

A) warm, flushed skin B) hunger and thirst C) increase urinary output D) palpitation and weakness 27. A client admitted to the hospital and diagnosed with Addisons disease. What would be the appropriate nursing action to the client? A) administering insulin-replacement therapy B) providing a low-sodium diet C) restricting fluids to 1500 ml/day D) reducing physical and emotional stress 28. The nurse is to perform tracheal suctioning. During tracheal suctioning, which nursing action is essential to prevent hypoxemia? A) aucultating the lungs to determine the baseline data to assess the effectiveness of suctioning B) removing oral and nasal secretions C) encouraging the patient to deep breathe and cough to facilitate removal of upper-airway secretions D) administering 100% oxygen to reduce the effects of airway obstruction during suctioning. 29. An infant is admitted and diagnosed with pneumonia and suspicious-looking red marks on the swollen face resembling a handprint. The nurse does further assessment to the client. How would the nurse document the finding? A) Facial edema with ecchymosis and handprint mark: crackles and wheezes B) Facial edema, with red marks; crackles in the lung C) Facial edema with ecchymosis that looks like a handprint D) Red bruise mark and ecchymosis on face 30. On the evening shift, the triage nurse evaluates several clients who were brought to the emergency department. Which in the following clients should receive highest priority? A) an elderly woman complaining of a loss of appetite and fatigue for the past week B) A football player limping and complaining of pain and swelling in the right ankle C) A 50-year-old man, diaphoretic and complaining of severe chest pain radiating to his jaw D) A mother with a 5-year-old boy who says her son has been complaining of nausea and vomited once since noon 31. A 80-year-old female client is brought to the emergency department by her caregiver, on the nurses assessment; the following are the manifestations of the client: anorexia, cachexia and multiple bruises. What would be the best nursing intervention?

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A) check the laboratory data for serum albumin, hematocrit, and hemoglobin B) talk to the client about the caregiver and support system C) complete a police report on elder abuse D) complete a gastrointestinal and neurological assessment 32. The night shift nurse is making rounds. When the nurse enters a clients room, the client is on the floor next to the bed. What would be the initial action of the nurse? A) chart that the patient fell B) call the physician C) chart that the client was found on the floor next to the bed D) fill out an incident report 33. The nurse on the night shift is about to administer medication to a preschooler client and notes that the child has no ID bracelet. The best way for the nurse to identify the client is to ask: A) The adult visiting, The childs name is ____________________? B) The child, Is your name____________? C) Another staff nurse to identify this child D) The other children in the room what the childs name is 34. The nurse caring to a client has completed the assessment. Which of the following will be considered to be the most accurate charting of a lump felt in the right breast? A) abnormally felt area in the right breast, drainage noted B) hard nodular mass in right breast nipple C) firm mass at five clock, outer quadrant, 1cm from right nipple D) mass in the right breast 4cmx1cm 35. The physician instructed the nurse that intravenous pyelogram will be done to the client. The client asks the nurse what is the purpose of the procedure. The appropriate nursing response is to: A) outline the kidney vasculature B) determine the size, shape, and placement of the kidneys C) test renal tubular function and the patency of the urinary tract D) measure renal blood flow 36. A client visits the clinic for screening of scoliosis. The nurse should ask the client to: A) bend all the way over and touch the toes B) stand up as straight and tall as possible C) bend over at a 90-degree angle from the waist D) bend over at a 45-degree angle from the waist 37. A client with tuberculosis is admitted in the

hospital for 2 weeks. When a clients family members come to visit, they would be adhering to respiratory isolation precautions when they: A) wash their hands when leaving B) put on gowns, gloves and masks C) avoid contact with the clients roommate D) keep the clients room door open 38. An infant is brought to the emergency department and diagnosed with pyloric stenosis. The parents of the client ask the nurse, Why does my baby continue to vomit? Which of the following would be the best nursing response of the nurse? A) Your baby eats too rapidly and overfills the stomach, which causes vomiting B) Your baby cant empty the formula that is in the stomach into the bowel C) The vomiting is due to the nausea that accompanies pyloric stenosis D) Your baby needs to be burped more thoroughly after feeding 39. A 70-year-old client with suspected tuberculosis is brought to the geriatric care facilities. An intradermal tuberculosis test is schedule to be done. The client asks the nurse what is the purpose of the test. Which of the following would be the best rationale for this? A) reactivation of an old tuberculosis infection B) increased incidence of new cases of tuberculosis in persons over 65 years old C) greater exposure to diverse health care workers D) respiratory problems are characteristic in this population 40. The nurse is making a health teaching to the parents of the client. In teaching parents how to measure the area of induration in response to a PPD test, the nurse would be most accurate in advising the parents to measure: A) both the areas that look red and feel raised B) The entire area that feels itchy to the child C) Only the area that looks reddened D) Only the area that feels raised 41. A community health nurse is schedule to do home visit. She visits to an elderly person living alone. Which of the following observation would be a concern? A) Picture windows B) Unwashed dishes in the sink C) Clear and shiny floors D) Brightly lit rooms 42. After a birth, the physician cut the cord of the baby, and before the baby is given to the mother, what would be the initial nursing action of the nurse?

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A) examine the infant for any observable abnormalities B) confirm identification of the infant and apply bracelet to mother and infant C) instill prophylactic medication in the infants eyes D) wrap the infant in a prewarmed blanket and cover the head 43. A 2-year-old client is admitted to the hospital with severe eczema lesions on the scalp, face, neck and arms. The client is scratching the affected areas. What would be the best nursing intervention to prevent the client from scratching the affected areas? A) elbow restraints to the arms B) Mittens to the hands C) Clove-hitch restraints to the hands D) A posey jacket to the torso 44. The parents of the hospitalized client ask the nurse how their baby might have gotten pyloric stenosis. The appropriate nursing response would be: A) There is no way to determine this preoperatively B) Their baby was born with this condition C) Their baby developed this condition during the first few weeks of life D) Their baby acquired it due to a formula allergy 45. A male client comes to the clinic for checkup. In doing a physical assessment, the nurse should report to the physician the most common symptom of gonorrhea, which is: A) pruritus B) pus in the urine C) WBC in the urine D) Dysuria 46. Which of the following would be the most important goal in the nursing care of an infant client with eczema? A) preventing infection B) maintaining the comfort level C) providing for adequate nutrition D) decreasing the itching 47. The nurse is making a discharge instruction to a client receiving chemotherapy. The client is at risk for bone marrow depression. The nurse gives instructions to the client about how to prevent infection at home. Which of the following health teaching would be included? A) Get a weekly WBC count B) Do not share a bathroom with children or pregnant woman C) Avoid contact with others while receiving chemotherapy D) Do frequent hand washing and maintain good hygiene

48. The nurse is assigned to care the client with infectious disease. The best antimicrobial agent for the nurse to use in handwashing is: A) Isopropyl alcohol B) Hexachlorophene (Phisohex) C) Soap and water D) Chlorhexidine gluconate (CHG) (Hibiclens) 49. The mother of the client tells the nurse, Im not going to have my baby get any immunization. What would be the best nursing response to the mother? A) You and I need to review your rationale for this decision B) Your baby will not be able to attend day care without immunizations C) Your decision can be viewed as a form of child abuse and neglect D) You are needlessly placing other people at risk for communicable diseases 50. The nurse is teaching the client about breast self-examination. Which observation should the client be taught to recognize when doing the examination for detection of breast cancer? A) tender, movable lump B) pain on breast self-examination C) round, well-defined lump D) dimpling of the breast tissue Answer and Rationale: Board Exam Nursing Test I NLE 1. D. Bathing an infant with eczema can be safely delegated to an aide; this task is basic and can competently performed by an aid. 2. B. The RN floated from the telemetry unit would be least prepared to care for a young infant who has just had GI surgery and requires a specific feeding regimen. 3. C. RN floated from the obstetrics unit should be able to care for a client with major abdominal surgery, because this nurse has experienced caring for clients with cesarean births. 4. A. The patient is experiencing a potentially serious complication related to diabetes and needs ongoing assessment by an RN 5. D. It describes functional nursing. Staff is assigned to specific task rather than specific clients. 6. B. Case management. The nurse assumes total responsibility for meeting the needs of the client during her entire duty. 7. B. The nurse is ethically obligated to inform the person responsible for the assignment and the person responsible for the unit about the nurses skill level. The nurse therefore avoids a

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situation of abandoningclients and exposing them to greater risks 8. A. This describes a mentor 9. B. This action demonstrates a lack of responsibility and the nurse should attempt negotiation with the nurse manager. 10. B. The team leader is responsible for the overall management of all clients and staff on the team, and this information is essential in order to accomplish this 11. C. Even though the mother is a minor, she is legally able to sign consent for her own child. 12. B. This response is the most direct and immediate. This is a case of potential need for advocacy and patients rights. 13. D. The nurse who witness a consent for treatment or surgery is witnessing only that the client signed the form and that the clients condition is as indicated at the time of signing. The nurse is not witnessing that the client is informed. 14. C. Although the statements by the mother may not create a suspicion of neglect, when they are coupled with observations about impaired bonding and maternal attachment, they may impose the obligation to report child neglect. The nurse is further obligated to notify caregivers of refusal to consent to treatment 15. C. It best explains what informed consent is and provides for legal rights of the patient 16. B. The physician may not be aware of the role that religious beliefs play in making a decision about surgery. 17. A. The behavior should be stopped. The first step is to remind the staff that confidentiality may be violated 18. C. Waiting for emotions to dissipate and sitting down with the colleague is the first rule of conflict resolution. 19. C. The nurse has no idea who the person is on the phone and therefore may not share the information even if the patient gives permission 20. A. The priority is to let the surgeon know, who in turn may ask the husband to sign the consent. 21. A. Phenytoin (Dilantin) can cause venous irritation due to its alkalinity, therefore it should be mixed with normal saline. 22. A. This position increases venous return, improves cardiac volume, and promotes adequate ventilation and cerebral perfusion 23. D. Checking the airway would be a priority, and a neck injury should be suspected 24. D. Client with Parkinsons disease are at a

high risk for aspiration and undernutrition. Sitting upright promotes more effective swallowing. 25. C. It is important to protect the RNs eyes from the possible contamination of coughed-up secretions 26. D. There has been too little food or too much insulin. Glucose levels can be markedly decreased (less than 50 mg/dl). Severe hypoglycemia may be fatal if not detected 27. D. Because the clients ability to react to stress is decreased, maintaining a quiet environment becomes a nursing priority. Dehydration is a common problem in Addisons disease, so close observation of the clients hydration level is crucial. 28. D. Presuctioning and postsuctioning ventilation with 100% oxygen is important in reducing hypoxemia which occurs when the flow of gases in the airway is obstructed by the suctioning catheter. 29. B. This is an example of objective data of both pulmonary status and direct observation on the skin by the nurse. 30. C. These are likely signs of an acute myocardial infarction (MI). An acute MI is a cardiovascular emergency requiring immediate attention. Acute MI is potentially fatal if not treated immediately. 31. D. Assessment and more data collection are needed. The client may have gastrointestinal or neurological problems that account for the symptoms. The anorexia could result from medications, poor dentition, or indigestion, and the bruises may be attributed to ataxia, frequent falls, vertigo or medication. 32. B. This is closest to suggesting actionassessment, rather than paperwork- and is therefore the best of the four. 33. C. The only acceptable way to identify a preschooler client is to have a parent or another staff member identify the client. 34. C. It describes the mass in the greatest detail. 35. C. Intravenous pyelogram tests both the function and patency of the kidneys. After the intravenous injection of a radiopaque contrast medium, the size, location, and patency of the kidneys can be observed by roentgenogram, as well as the patency of the urethra and bladder as the kidneys function to excrete the contrast medium. 36. C. This is the recommended position for screening for scoliosis. It allows the nurse to inspect the alignment of the spine, as well as to compare both shoulders and both hips. 37. A. Handwashing is the best method for reducing cross-contamination. Gowns and gloves are not always required when entering a clients

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room. 38. B. Pyloric stenosis is an anomaly of the upper gastrointestinal tract. The condition involves a thickening, or hypertrophy, of the pyloric sphincter located at the distal end of the stomach. This causes a mechanical intestinal obstruction, which leads to vomiting after feeding the infant. The vomiting associated with pyloric stenosis is described as being projectile in nature. This is due to the increasing amounts of formula the infant begins to consume coupled with the increasing thickening of the pyloric sphincter. 39. B. Increased incidence of TB has been seen in the general population with a high incidence reported in hospitalized elderly clients. Immunosuppression and lack of classic manifestations because of the aging process are just two of the contributing factors of tuberculosis in the elderly. 40. D. Parents should be taught to feel the area that is raised and measure only that. 41. C. It is a safety hazard to have shiny floors because they can cause falls. 42. D. The first priority, beside maintaining a newborns patent airway, is body temperature. 43. B. The purpose of restraints for this child is to keep the child from scratching the affected areas. Mittens restraint would prevent scratching, while allowing the most movement permissible. 44. C. Pyloric stenosis is not a congenital anatomical defect, but the precise etiology is unknown. It develops during the first few weeks of life. 45. B. Pus is usually the first symptom, because the bacteria reproduce in the bladder. 46. A. Preventing infection in the infant with eczema is the nurses most important goal. The infant with eczema is at high risk for infection due to numerous breaks in the skins integrity. Intact skin is always the infants first line of defense against infection. 47. D. Frequent hand washing and good hygiene are the best means of preventing infection. 48. D. CHG is a highly effective antimicrobial ingredient, especially when it is used consistently over time. 49. A. The mother may have many reasons for such a decision. It is the nurses responsibility to review this decision with the mother and clarify any misconceptions regarding immunizations that may exist. 50. D. The tumor infiltrates nearby tissue, it can cause retraction of the overlying skin and create a dimpling appearance.

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